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Summer Activities Program Registration

(Please use a separate form for each child and for each class)

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SUMMER PROGRAM SESSION 2014

Choose the week you would like your child to attend.

  • June 23 - 27
  • June 30 - July 4
  • July 7 - 11
  • July 14 - 18
  • July 21 - 25
  • July 28 - August 1
  • August 4 - 8
  • August 11 - 15
  • August 18 - 22
 

STUDENT INFORMATION

Student's Name:
Age:
Grade:
D.O.B:
Address:
City:
State:
ZIP:
Home Phone Number:

PARENT INFORMATION

Mother's Name:
Work Tel:
Mobile Tel:
Father's Name:
Work Tel:
Mobile Tel:
Can we contact you through E-Mail? Yes: No:
Parent's E-Mail:

MEDICAL INFORMATION AND EMERGENCY CONTACTS

Emergency Name and Contact Number:
Health Insurance Carrier
Are there any medical conditions we should know about? Yes:  No:
If yes, please explain:

Acknowledgment of Risk, Waiver of Liability and Photo Disclaimer:

As parents or legal guardian of (name of child) , I hereby consent to aforementioned participating dance and related activated with ABAKA. I recognize that potentially injuries can occur at any activity involving motion, including dance and related activities. I understand it is the express intent of ABAKA to provide for the safety and protection of my child and in consideration for allowing my child to use these facilities, I hereby forever release ABAKA, its officers, employees, and teachers for all liability for any and all damages suffered by my child while under the instruction, supervision or control of ABAKA or its employees. As parent or legal guardian of the aforementioned person, I hereby agree to individually provide for the possible future medical expenses, which may be incurred by my child as result of any injury, sustained while participating in dance class or related activities at ABAKA. This acknowledgment of risk and waiver of liability, having been read through thoroughly and understood completely, is signed voluntarily as to its content and intent.
By signing this form, I agree to allow my child/children's images to be used on Abaka website or other media. If you do not want your children's images to be used, you must mail a certified letter stating your disagreement to the photo policy.

BY CHECKING THIS BOX, I CONFIRM THAT I HAVE READ AND AGREE WITH THE "ACKNOWLEDGEMENT OF RISK AND WAIVER OF LIABILITY".

PLEASE ENTER THE IMAGE CODE BELOW!

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