Stretching for Life Student Registration

Student Registration
Choose One*

Returning StudentNew Student

Parent/Guardian Information
Parent/Guardian 1*

PrefixFirst NameMiddle NameLast NameSuffix
Relationship to Student*
Gender*

FemaleMaleOther
Address (If different than above)

Street Address

Street Address Line 2

CityState

Zip Code
Email*
If not applicable, type N/A.
Phone Number*

Area CodePhone Number
Employer*
Parent/Guardian 2

PrefixFirst NameMiddle NameLast NameSuffix
Relationship to Student
Gender

FemaleMaleOther
Address (If different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
If not applicable, type N/A
Phone Number

Area CodePhone Number
Employer
Would you like to join our Email Newsletter?*

Yes (Already receive newsletter)Yes (New Member)No

Pick - Up Information

Two people authorized to pick up student (other than parent/guardian)
Name*

First NameLast Name
Relationship to Student*
Phone Number*

Area CodePhone Number
Emergency Contact?*

YesNo
Name*

First NameLast Name
Relationship to Student*
Phone Number*

Area CodePhone Number
Emergency Contact?*

YesNo
Please check all statements after you've read and understand each statement.*

I authorize and consent for my child/ children to participate in Spectrum in Motion Dance Theater Ensemble’s educational program,Stretching for LIFE. I understand that my child / children must stay for the entire session and attend a minimum of 80% of their child's program. Failure to comply will result in my child / children being removed from the program.I give permission to my child/children to sign themselves out to walk or take the bus home at the completion of daily programming. (Must be at least 13)

Unauthorized Persons for Pick - Up or Contact

If applicable, please list any individual(s) NOT AUTHORIZED to pick-up or be in contact with student while in the care of Spectrum in Motion Dance Theatre Ensemble.
Name

First NameLast Name
Relationship to Student
Name

First NameLast Name
Relationship to Student

Medical Information

It is extremely important that Spectrum in Motion Staff Members are made aware of any medications or health issues that a participant (apprentice, student, or intern) may have, in order to provide a safe working environment for everyone. This information is required.
Student's Name*

First NameLast Name
Primary Policy Holder's Name*

First NameLast Name
Insurance Company*
Insurance Policy Number*
Insurance Group Number*
If not applicable, type N/A
Physican*
Physician Phone Number*

Area CodePhone Number
Hospital Preference*
Please List ALL Medical Conditions/Allergies*
If your child has any medical conditions, i.e. asthma, allergies (bees, nuts/peanuts, etc.), diabetes, epilepsy, etc., that Spectrum in Motion should be aware of in order to protect his/her health, please provide this information HERE. If you list an allergy please provide details about the severity of the reaction. If not applicable, type N/A.
My child DOES NOT have any medical conditions nor does he/she require any medication that Spectrum in Motion's Staff needs to be aware of.

I certify that the statement above is true to the best of my knowledge.
In case of Medical Emergency

In case of a Medical Emergency, I wish for Spectrum in Motion to contact the following people:
Name for First Call*

First NameLast Name
Phone Number*

Area CodePhone Number
Name for Second Call

First NameLast Name
Phone Number

Area CodePhone Number

Release Form

Please read each statement and agree to it by checking each box next to the statement.
Waiver of Liability: I acknowledge that I am aware that the activities associated with this program entail certain inherent risks including damage to property, personal injury, and even death. I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever release and discharge Spectrum in Motion Dance Theater Ensemble,Inc, Asylum Hill Congregational Church, their representatives, affiliated agencies, officers, sponsors, trustees, successors, insurers, assigns, or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities, or participation in the activities of said organization either at or away from the location.Medical Treatment: I give my permission for Spectrum in Motion to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment. I give my permission for the Spectrum in Motion staff to provide emergency health care, administer prescriptions medication, and seek emergency medical treatment including ordering x-rays and/or routine tests. In the event that I cannot be reached in an emergency, I hereby give permission to the appropriate physician selected by the hospital to; hospitalize, secure proper treatment, and to order injection and/or anesthesia and/or surgery for my child.Data Collection: I give permission to Spectrum in Motion to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any, and all, information will be kept strictly confidential. Data gathered through these means may be shared withSpectrum in Motion staff, funders, grant writers, and other community stakeholders to show evidence of the program effectiveness and impact on our students.Field Trips & Transportation: I give permission for my child to attend any field trip organized by Spectrum in Motion and I authorize Spectrum in Motion to transport my child by bus, or on foot to other local locations, including but not limited to; Bushnell Park, Connecticut Science Center, Hartford Public Library, ConnecticutHistorical Society, and Elizabeth Park, as scheduled. I also give permission for my child to be transported in a private vehicle, driven by a Spectrum in Motion staff member or volunteer, if necessary.Miscellaneous: I give permission for all photographs, film/videos, and audiotapes taken of my child to be used by Spectrum in Motion for publicity, publications, fundraising, or websites. I authorize Spectrum in MotionDance Theater Ensemble, Inc. to use my child’s image, voice and/or artwork in the production of audio or visual material for the purpose of promoting and documenting the program. All media that use such image, voice, or artwork will be without compensation and will be the property of the Spectrum inMotion.I understand that Spectrum in Motion is not responsible for lost or stolen items.

We thank you for choosing Spectum in Motion Dance Theatre Ensemble. As a Community Conservatory, we take the pride in offering the best and most rigor knowledge to your children. It is with great honor and care that we welcome you to the Spectrum Family!
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Registration Fee$25.00

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Student Registration

Student Demographics

Parent/Guardian Information

Pick - Up Information

Unauthorized Persons for Pick - Up or Contact

Medical Information

In case of Medical Emergency

Release Form

Code of Conduct

Tuition Policies & Financial Obligations