Chance to Dance 2024

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We are excited to have you join us for a Chance to Dance and a night to remember! Please fill out the form below to sign up and we will be in touch with you! We look forward to seeing you April 14th from 4-7PM at the Barn at Melan Farms in Baxley, GA!

Name? *

Age ? *

Date of Birth *

YYYY

Gender *

Male

Female

Address *

City, State *

Emergency Contact *

Emergency Contact Phone Number *

Health Concerns

Wheelchair/Accessibility Device Dependent? *

Yes

Special Communication Needs (if so, please explain) Type NO if none *

Sensory issues (strobe lights, camera flashes, loud noises etc.) Type NO if none *

Allergies (please list ANY that apply) If none, please type none *

Food Needs (cut-up, pureed, gluten-free etc.) If yes, please explain

Will medication need to be administered during the event? (Please note that our volunteers are not responsible for administering medication to guests during the event. If medication is required during the event, a PARENT or CARETAKER must be available to administer the medication. *

Yes

PARENT/CARETAKER NAME *

PARENT/CARETAKER PHONE NUMBER *

HOW MANY TOTAL PEOPLE WILL BE ATTENDING WITH YOU? (Including Student) *

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