Registration
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Drop your kids off at CDL for an evening of Holiday Magic while you tackle your Christmas To Do List
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
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Family Information
First Name:
*
Last Name:
*
Type
*
Aunt
Dancer
Father
Foster Parent
Grandparent
Guardian
Mother
Other
Parent
Sibling
Step-Parent
Uncle
Home Phone:
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Cell #:
Work #:
Email:
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(Emails are kept confidential)
Address:
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City:
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State/Prov:
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Alberta
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Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
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Ontario
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Postal Code:
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Emergency Contact Info (Please enter someone other than Primary Contact)
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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:
*
Student Gender:
*
Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
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preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #2:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #3:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #4:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #5:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Additional Information:
Liability Release
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As the legal parent or guardian, I hereby give my approval for participation in physical activities offered through Connectivity Dance Ltd and all registered trademarks there of, which includes the Connectivity Skippers. I understand that while in the building or care of Connectivity Dance staff, my child is to adhere to the studio policies. I furthermore release and hold harmless Connectivity Dance Ltd. it's owners, shareholders, administrators, instructors and volunteers from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while participating in any classes, programs or events while in or upon the premises or any premises under the control and supervision of Connectivity Dance Ltd., it's owners, administrators, instructors and volunteers or in route to or from any of said premises.
I've read the above and agree.
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