Registration

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Parents Night Out - December 1 - 5:30pm - 8:30pm Enjoy a night out while your kid enjoys and fun night of games and activities. Pizza and drink included.

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Type*
	Home Phone:	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info (Not Contact #1 or #2)*

Students entered below will be added to your family's account

Add New Student #1:

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	Student's First Name: *	Last Name: *
	Birth Date: *	(format=mm/dd/yyyy)
	Student Email:
	School:	Grade Level:
	Disabilities (NA if None):*
	Allergies (NA if None):*
	Medications (Leave blank if NONE):
	Previous Injuries:
	Physical Conditions:
	Race-Ethnicity(ies):*
	Preferred Pronouns:*

Add New Student #2:

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	Student's First Name: *	Last Name: *
	Birth Date: *	(format=mm/dd/yyyy)

	Student Email:
	School:	Grade Level:
	Disabilities (NA if None):*
	Allergies (NA if None):*
	Medications (Leave blank if NONE):
	Previous Injuries:
	Physical Conditions:
	Race-Ethnicity(ies):*
	Preferred Pronouns:*

Add New Student #3:

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	Student's First Name: *	Last Name: *
	Birth Date: *	(format=mm/dd/yyyy)

	Student Email:
	School:	Grade Level:
	Disabilities (NA if None):*
	Allergies (NA if None):*
	Medications (Leave blank if NONE):
	Previous Injuries:
	Physical Conditions:
	Race-Ethnicity(ies):*
	Preferred Pronouns:*

Add New Student #4:

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	Student's First Name: *	Last Name: *
	Birth Date: *	(format=mm/dd/yyyy)

	Student Email:
	School:	Grade Level:
	Disabilities (NA if None):*
	Allergies (NA if None):*
	Medications (Leave blank if NONE):
	Previous Injuries:
	Physical Conditions:
	Race-Ethnicity(ies):*
	Preferred Pronouns:*

Add New Student #5:

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	Student's First Name: *	Last Name: *
	Birth Date: *	(format=mm/dd/yyyy)

	Student Email:
	School:	Grade Level:
	Disabilities (NA if None):*
	Allergies (NA if None):*
	Medications (Leave blank if NONE):
	Previous Injuries:
	Physical Conditions:
	Race-Ethnicity(ies):*
	Preferred Pronouns:*

Additional Information:

Assumption of Risk

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I assume any and all risk of injury (serious or otherwise) for me or my child. I further agree that if someone else is harmed through my child’s actions and blames the gym/venue, its owners, or its employees, for his harm, I will indemnify, defend, and old harmless the gym/venue, its owners, or its employees.

In consideration of being permitted to participate in aerial dance activities including but not limited to Rope and Harness, Fabric and Trapeze (hereafter known as Aerial Dance Activities) at and/or under the auspices of Caroline Calouche & Co. / Charlotte Cirque & Dance Center, I do acknowledge, appreciate and agree that:

**The risk of injury resulting from Aerial Dance Activities is significant. The risk includes but is not limited to all manner of injury resulting from my falling during Aerial Dance Activities and hitting the floor, wall faces, people, rope, fabric, and fixtures – whether permanently or temporarily in place. This risk also includes, but is not limited to, rope/fabric abrasion, rope/fabric entanglement and burn, injuries resulting from falling and dropped items.

I do knowingly and freely assume all such risks both known and unknown, and I do knowingly and freely assume all responsibility for my participation in dance and cirque activities at and/or under the auspices of Caroline Calouche & Co. /Charlotte Cirque & Dance Center