Registration Form

Gye Nyame Youth Dance Ensemble

Fall 2018 Class Registration
8 weeks beginning Saturday October 27 2018 Ages 3 -8: 10:00 am -11:00 am Age 9 -15: 11:00 am - 12 pm COST: $10 per class, payable on the first day of class. WHERE: Davin Drums Studio 2245 Julius Felder Street, Suite 3A, Cayce, SC
Student Information
Student's Name

First NameLast Name
Dance Experience

No dance experienceSome dance experienceFormal dance experience
Birth Date

MonthDayYear
Grade
Gender

FemaleMale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in activities prepared by Gye Nyame Dance Ensemble during the class. In exchange for the acceptance of said child’s candidacy by Gye Nyame Dance Ensemble, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Gye Nyame Dance Ensemble and all its respective representatives from any and all liability for injuries to said child arising out of participating in classes.
Confirmation

BY SUBMITTING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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Gye Nyame Youth Dance Ensemble