Registration
Event:
Start Date/Time:
End Date/Time:
Fee per Family:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
Caregiver
Father
Guardian
Mother
Parent
Self
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Contact Info (Not Contact #1 or #2)
*
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non-Binary
Transgender
Birth Date:
*
(format=mm/dd/yyyy)
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies:
*
Medications:
*
Primary Doctor:
Food Allergies (Y/N); Describe:
Race/Ethnicity:
*
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non-Binary
Transgender
Birth Date:
*
(format=mm/dd/yyyy)
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies:
*
Medications:
*
Primary Doctor:
Food Allergies (Y/N); Describe:
Race/Ethnicity:
*
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non-Binary
Transgender
Birth Date:
*
(format=mm/dd/yyyy)
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies:
*
Medications:
*
Primary Doctor:
Food Allergies (Y/N); Describe:
Race/Ethnicity:
*
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non-Binary
Transgender
Birth Date:
*
(format=mm/dd/yyyy)
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies:
*
Medications:
*
Primary Doctor:
Food Allergies (Y/N); Describe:
Race/Ethnicity:
*
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non-Binary
Transgender
Birth Date:
*
(format=mm/dd/yyyy)
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies:
*
Medications:
*
Primary Doctor:
Food Allergies (Y/N); Describe:
Race/Ethnicity:
*
Questions/Options:
Are you affiliated with a church or Dance Ministry?
Yes
No
Please name the church or ministry you are apart of.
Additional Information:
Photo Release
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I hereby grant Iibada Dance Company permission to use my likeness in a photograph, video, or other digital media (photo) in any and all of its publications, including web-based publications, without payment or other consideration for current and future promotions for this event.
I've read the above and agree.
Assumption Risk
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Assumption of Risk
I acknowledge, that this workshop carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I understand and appreciate these and other risks are inherent in the activity I am participating in. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
Credit Card Verification:
Card Number:
Visa
Mastercard
Amex
Discover
Name as it appears on card:
Nickname:
Card Expiration Month:
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
Address Line 1:
Address Line 2:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
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