Start Date/Time: End Date/Time:
Fee per Family: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Emergency Contact Info
(Not Contact #1 or #2)*
Are you affiliated with a church or Dance Ministry?
Please name the church or ministry you are apart of.
Additional Information:
Photo Release
I hereby grant Iibada Dance Company permission to use my likeness in a photograph, video, or other digital media (photo┬Ł) 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
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:  
Name as it appears on card:
Card Expiration Month:   Exp Year:
Address Line 1: Address Line 2:
City: State: Zip: