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Relentless Purpose - Dancer Intake Form

Hello Please fill out the required information for each dancer listed in your household. Also, add the contact information of the person that should be listed as the emergency contact. All Parents should submit there information for contact needs.


Adult Dancer / PARENT OR LEGAL GUARDIAN INFORMATION 

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code

Optional - Spouse / Parent or Legal Guardian Information 

Optional - Spouse / Parent or Legal Guardian First Name:
Optional - Spouse / Parent or Legal Guardian Last Name:
Optional - Spouse / Parent or Legal Guardian Email Address:
Optional - Spouse / Parent or Legal Guardian Phone Number:

Parent Consent/Media and Liability


PARENT CONSENT

a)   I agree to myself, and/or my son/ daughter taking part in the activities of the ministry.

b)   I confirm to the best of my knowledge that myself, and/or my son/ daughter does not suffer from any medical condition other than those listed below. 


PHOTO/VIEDO PERMISSION & RELEASE   

Agrees to grant to Relentless Church the absolute right and permission to use Participant’s name and likeness and to copyright, and/or use, and/or publish photographs and/or video and sound recordings of Participant for broadcast, publication or any lawful purpose. Participant RELEASES, DISCHARGES, AND AGREES TO HOLD HARMLESS RELENTLESS CHURCH FROM ANY LIABILITY FOR ANY USE OF THE PHOTOGRAPHS AND VIDEOS.


RELEASE OF LIABILITY

Agrees to protect, defend, and hold Relentless Church harmless from and against any and all claims, demands, causes of action of every kind and character, losses, costs, expenses including attorney’s fees and damages of every kind and character for injury or death and any damage or alleged damage to any property sustained or alleged to have been sustained arising out of, or relating to or incident to Participant’s participation in the Activity, regardless of whether such claims, demands, causes of action of every kind and character, losses, costs, expenses including attorney’s fees and damages are caused by the sole, joint or concurrent negligence of Relentless Church or their agents or employees. Participant hereby waives any and all claims, demands, and causes of action, of every kind and character for personal injury or property damage related to participation in the Activity.


*ACKNOWLEDGEMENT:

BY REGISTERING ONLINE FOR THE ABOVE EVENT, I HEREBY ACKNOWLEDGE THAT I HAVE READ, COMPREHEND, AND VOLUNTARILY AGREE TO FULLY COMPLY WITH ALL PARENT CONSENT / MEDIA & LIABILITY AS OUTLINED HEREIN PURSUANT TO THE 2018-19 PARENT CONSENT / MEDIA & LIABILITIES OF ON-LINE REGISTRATION REQUIREMENTS OF RELENTLESS CHURCH.

Emergency Contact Information 

*Emergency Contact First and Last Name:
*Emergency Contact Phone Number:

Dancer 1

*Dancer's First Name
*Dancer's Last Name
*Dancer's Gender
*Dancer's Birthdate
*Dancer's Age/Grade
(As of September 1st, 2017)
*Dancer's Allergies/Special Needs
*Dancer's - EXPERIENCE LEVEL
*Dancer's Teaching Experience
*Dancer's Genre Experience

Dancer 2

Dancer's First Name
Dancer's Last Name
Dancer's Gender
Dancer's Birthdate
Dancer's Age/Grade
(As of September 1st, 2017)
Dancer's Allergy/special Needs
Dancer's - EXPERIENCE LEVEL
Dancer's Teaching Experience
Dancer's Genre Experience

Dancer 3

Dancer's First Name
Dancer's Last Name
Dancer's Gender
Dancer's Birthdate
Dancer's Age/Grade
(As of September 1st, 2017)
Dancer's Allergy/special Needs
Dancer's - EXPERIENCE LEVEL
Dancer's Teaching Experience
Dancer's Genre Experience

Dancer 4

Dancer's First Name
Dancer's Last Name
Dancer's Gender
Dancer's Birthdate
Dancer's Age/Grade
(As of September 1st, 2017)
Dancer's Allergies/Special Needs
Dancer's - EXPERIENCE LEVEL
Dancer's Teaching Experience
Dancer's Genre Experience

Dancer 5

Dancer's First Name
Dancer's Last Name
Dancer's Gender
Dancer's Birthdate
Dancer's Age/Grade
(As of September 1st, 2017)
Dancer's Allergies/Special needs
Dancer's - EXPERIENCE LEVEL
Dancer's Teaching Experience
Dancer's Genre Experience

Will You Be Needing Childcare?

*Select below:
*Please add the following information below: (Child(ren) Name(s), Birthday, Grade & Allergies) and/or any other information that is needed. 

** Note place N/A if not applicable 

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