Yalenka Registration Form for 2007-2008 Season

NAME : ______________________________________________MALE: ___  FEMALE: ______

BIRTHDATE : ____________________________ TELEPHONE : _________________________

ADDRESS : ___________________________________________  EMAIL : ________________

NAME OF PARENTS/GUARDIANS : _______________________________________________

PREVIOUS DANCE EXPERIENCE : _________________________________________________

ENHANCEMENT CLASS :   YES : ______   NO : ______

ARE YOU INTERESTED IN SOLO OR DUET PERFORMANCES?   YES : ______   NO : ______ 

LIABILITY RELEASE

Do you have any allergies  ? Yes/No  If Yes, what are they ? _______________________________

HEALTH CARE NUMBER : _______________________________________________________

DOCTOR’S NAM E : ________________________________________ PHONE # : ___________

If unable to contact parent or guardian in case of emergency, please give another contact person.

NAME : __________________________________________________ PHONE # : ___________

DATE : ___________  PARENTS/GUARDIANS’ SIGNATURE : ___________________________ 

CONSENT TO PHOTOGRAPH, VIDEOTAPE AND/OR AUDIOTAPE

The purpose is to record your consent to allow your child’s existing photographs, videotapes and/or audiotapes for the specified use.
I GIVE / DO NOT GIVE permission for Yalenka Ukrainian Dancers Society to use photographs, videotapes, and/or audiotape recordings of   __________________________________________________

DATE : ________________  PARENTS/GUARDIANS’ SIGNATURE ____________________________

PLEASE NOTE : In addition to the class fee, a $150.00 deposit will be required for volunteering, but not cashed.  If you volunteer 5 hours or more during the course of the year, the volunteer deposit will be returned.