A Chance to Dance

Parent(s) Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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Dancer's Name & Nickname *

Dancer must be ages 6-12 to participate in our DD program

First Name

Last Name

Date of Birth *

MM

DD

YYYY

What would you like your coach assistant to do to help your dancer: *

Move in wheelchair/help with walking aids

Specialized care - please discuss with us personally

Other

Please check any of the following items that apply to your dancer: *

Sensitive to rough textures/fabrics

Allergic to perfumes/dyes/smells

Sensitive to lights

Bothered by loud sounds

Problems keeping on task/staying focused

Runs away from group or person in charge

Minimal help needed

Waiver *

Our High School & College age coaches are usually (but not mandatory) accomplished dancers who want to share what they love with your dancer. They will typically help with the following areas: help dancers stand, help with focus & following directions, help with safety issues related to stability, encourage verbally and with praise or hugs. If care is needed beyond this level, we will meet to see how we can work together to address needs. Students must be able to exhibit basic communication skills (dancers can be non-verbal, just need to be able to communicate at a basic level.) Students need to exhibit appropriate social behavior and general self-control that would be expected for their age with expected developmental disabilities. We are not trained to special education experts and are not equipped to work with all students including severe discipline problems or children with difficult medical care. We will seek to provide dance education to as many children as possible. Your child’s safety is of the utmost importance to us. If for any reason, you have concerns regarding the safety/treatment of your child, please notify the dance instructor, program coordinator and studio owner immediately.

Please read the information and check the box to acknowledge your understanding of the information above.

Photo and Video Release: *

Please read the following statements and sign at the bottom of the page by checking the box. By signing this release, I authorize the program to use the following personal information for my family and dancer: Pictures: Including photo, motion, electronic images Voices: including sound and video recording I grant the right to publish, reproduce for all purposes and copy my image as needed for the benefits of the organization. This includes but is not limited to print media and video recorded for the purpose of the program. I waive the rights for any compensation for the use of the photos, audio, media and for any finished photos, audio and video, advertising recording and copyrighted materials. Also, anything generated by a computer. By checking the below box I am acknowledging that I am signing for my under age child and on behalf of my family members and I am granting permission for my child to participate in all aspects of Darby’s Dancers.

I acknowledge that I have read the following and I am in full agreement with this document.

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Reference 1 *

First Name

Last Name

Phone *

(###)

###

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Reference 2 *

First Name

Last Name

Phone *

(###)

###

####

Reference 3 *

First Name

Last Name

Phone *

(###)

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Please check boxes if you are applying to be a Coach or are the Parent/Guardian of a Coach:

I understand that I am making a commitment to attend every practice and assist at recital and all other Darby’s Dancers functions. I agree to be respectful to the staff, students, and parents of Darby’s Dancers. I also agree to attend all coach training and meetings required for my position. I agree to be on time and if I am unable to attend for any reason to call the staff asap. I agree to dress in Saturday rehearsal attire to volunteer and complete my volunteer time sheet.

As a parent of a volunteer you agree to support their commitment by encouraging them to strive for good work habits and attendance, make sure they arrive on time and are picked up, and emphasize the importance of their responsibility to this program.

All volunteers may be photographed or on video for marketing. If you object, check here

Which class are you available to help with? *

Tuesday 5:15

Tuesday 5:45

Both classes