Registration Form
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sdc Registration Form for Shelley’s Dance Company Ltd. |
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Dancer Information: |
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Student's Name: Last First Age: |
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Date of Birth: dd/mm/yyyy |
Health Care Number: |
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Home Address: City: PC: |
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Phone: Res: ( ) Work: ( ) Cell: ( ) |
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School Attending: Grade: |
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E-mail address: |
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Parent/Guardian Information: |
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Name: Last First Contact Number: |
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Name: Last First Contact Number: |
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Address if different than dancer. |
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E-mail address: |
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Injury to Participate Waiver: It is understood and agreed that Shelley’s Dance Company Ltd. is not responsible for bodily injury or death to any person (s) practising, instructing or participating in any physical training or dance activity and the undersigned shall save and hold harmless the above mentioned party from any all such injury or death. |
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Dancer’s Signature /Parent’s Signature (if dancer under 18):
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Date:
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Emergency Contact (Please print) Allergy or Medical Alert – Yes No |
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Name: Contact Number: |
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Shelley’s Dance Company Ltd. Office Use Only: |
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Method of Payment: Make cheques payable to Shelley’s Dance Company. q Cash q Cheque # q VISA q Master Card |
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VISA / Master Card Number:
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Expiration Date: |
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Name of Card Holder: (Please print) |
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