Registration

First Dancer's First and Last Name*

Date of Birth*

Years of Experience*

Does your dancer want to do a solo, duet, trio or family dance?* Does your dancer want to do a solo, duet, trio or family dance?* Solo Duet Trio Family Dance Unsure

Second Dancer's First and Last Name

Date of Birth

Years of Experience

Does your dancer want to do a solo, duet, trio or family dance? Does your dancer want to do a solo, duet, trio or family dance? Solo Duet Trio Family Dance Unsure

Third Dancer's First and Last Name

Date of Birth

Years of Experience

Does your dancer want to do a solo, duet, trio or family dance? Does your dancer want to do a solo, duet, trio or family dance? Solo Duet Trio Family Dance Unsure

Parent/Guardian's Name*

Parent/Guardian's Address*

Parent/Guardian's Phone Number*

Parent/Guardian's Email*

Emergency Contact Name*

Emergency Contact Phone Number*

Emergency Contact Email*

Allergies or Special Considerations?

I do hereby release the Fort McMurray Ukrainian Cultural Society, Kasia Podilsky, and Nick Podilsky and all other instructors or students in any capacity for any liability due to injuries, etc that I may obtain as a result of my attendance or participation in any and all dance classes or any special event associated with this class or the Fort McMurray Ukrainian Cultural Society. I clearly understand that participation in this class will involve dance and bodily exercise and movement with rigorous activity. I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to participate in the classes for which I have registered.* I do hereby release the Fort McMurray Ukrainian Cultural Society, Kasia Podilsky, and Nick Podilsky and all other instructors or students in any capacity for any liability due to injuries, etc that I may obtain as a result of my attendance or participation in any and all dance classes or any special event associated with this class or the Fort McMurray Ukrainian Cultural Society. I clearly understand that participation in this class will involve dance and bodily exercise and movement with rigorous activity. I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to participate in the classes for which I have registered.* Yes No

I hereby give permission for the Fort McMurray Ukrainian Cultural Society, in conjunction with the Avrora Ukrainian Dance Group to: (1) release my phone number(s), email address and home address, to be used by the executive, instructors or any other volunteer person needing contact. (FOIPP).* I hereby give permission for the Fort McMurray Ukrainian Cultural Society, in conjunction with the Avrora Ukrainian Dance Group to: (1) release my phone number(s), email address and home address, to be used by the executive, instructors or any other volunteer person needing contact. (FOIPP).* Yes No

I hereby give permission for the Fort McMurray Ukrainian Cultural Society, in conjunction with the Avrora Ukrainian Dance Group to: (2) distribute the same contact information to all other Ukrainian Cultural Society families of the dancers and/or members. (FOIPP).* I hereby give permission for the Fort McMurray Ukrainian Cultural Society, in conjunction with the Avrora Ukrainian Dance Group to: (2) distribute the same contact information to all other Ukrainian Cultural Society families of the dancers and/or members. (FOIPP).* Yes No

I hereby give permission for the Fort McMurray Ukrainian Cultural Society, in conjunction with the Avrora Ukrainian Dance Group to: (3) my dancer’s image to appear on our website, newsletters, public displays and in the media. (FOIPP).* I hereby give permission for the Fort McMurray Ukrainian Cultural Society, in conjunction with the Avrora Ukrainian Dance Group to: (3) my dancer’s image to appear on our website, newsletters, public displays and in the media. (FOIPP).* Yes No

Questions?