WINTER INTENSIVE REGISTRATION
Event Address: TANNERY WORLD DANCE CENTER - 1060 RIVER STREET #110/111 SANTA CRUZ, CA. 95060
Contact us at (831)420-7184 or info@broadwayinsantacruz.com

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Email *
STUDENT INFORMATION:
Name: *
Phone Number: *
Birthdate/Age: *
Address: *
Gender: *
PARENT/GUARDIAN INFORMATION:
Name: *
PHONE NUMBER: *
EMAIL: *
EMERGENCY INFORMATION:
Emergency Contact's Name: *
Relationship: *
Required
Phone Number: *
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe *
Medical Insurance: *
Insurance Policy Number: *
Physician's Name and Phone Number: *
INFORMED CONSENT AND ACKNOWLEDGEMENT:
I hereby give my approval for my child’s participation in any and all activities prepared by during Summer Intensive. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless and all its respective teachers, agents, and representatives from any and all liability for injuries to said child arising out of participating in Summer Intensive session.In case of injury to said child, I hereby waive all claims against . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
MEDICAL RELEASE AND AUTHORIZATION:
As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Broadway in Santa Cruz and its affiliates including Directors, Teachers, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.Release authorized on the dates and/or duration of the registered session. *
Required
CONFIRMATION:
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. *
Required
HOW DID YOU HEAR ABOUT US: *
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