Ministries - Youth Ministries - Greek Folk Dance - Registration

Dancers will be placed on a team based on ability and age.



* Required information
Parent's Name: *
Address: *
City: *
State: *       Zip Code: *
Home Phone: *
Cell Phone:
Email: * Confirmation goes to this email.

Dancer's Name 1: *
Birth Date: *
Age: *
Cell Phone: *
Email: *
Health Issues? * Yes No - Please state any health issues / medication in the comments section below.
Please indicate: *
New dancer Returning dancer
Grade: *
 
Dancer's Name 2:
Birth Date:
Age:
Cell Phone:
Email:
Health Issues? Yes No - Please state any health issues / medication in the comments section below.
Please indicate:
New dancer Returning dancer
Grade: *
 
Dancer's Name 3:
Birth Date:
Age:
Cell Phone:
Email:
Health Issues? Yes No - Please state any health issues / medication in the comments section below.
Please indicate:
New dancer Returning dancer
Grade: *
 
Dancer's Name 4:
Birth Date:
Age:
Cell Phone:
Email:
Health Issues? Yes No - Please state any health issues / medication in the comments section below.
Please indicate:
New dancer Returning dancer
Grade: *

Are you a current steward of a Greek Orthodox Church? *   Yes   No
What Parish are you a steward of? *


     Other Home Parish: (include parish name, city, and state)
     

Emergency Authorization

I/We the undersigned dancer/parent(s)/legal guardian(s) of the registered dancer, do hereby authorize the dance directors, Parish Priest or parents of the group acting in the capacity of activity supervisor/vehicle driver, as agents for the undersigned to consent to medical, surgical or dental examination, treatment, etc. In case of emergency, I/We hereby authorize treatment and/or care of registered dancer at any hospital. If there is an emergency and I/We cannot be reached, please contact the emergency contact person stated below whom is hereby authorized to act in the dancerís behalf.

 
Emergency Contact: *
Home Phone: *
Cell Phone: *
 
  If you wish to have a family doctor contacted in case of emergency, please list:
Doctor's Name:
Phone:
Insurance Carrier:
 
Please state any health issue(s) and any regular medication below. Please include names if you are registering more than one dancer.
Comments:

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