Registration | Eileen Moore Dance Academy

Parent/Guardians Name *

Students Name *

Date Of Birth *

Age *

Address & Eircode *

Mobile Number *

Work/Home Number

Email address *

Emergency Contact & Relationship to child *

What class are you registering your child for ? ie. Grade 3 Ballet Saturday. (If unsure which class your child will be in from September, please write the time and day of the class they were in last term if applicable) *

Previous Dance Experience. Please tick any that apply. *

Ballet
Modern
Tap
Contempary
Irish Dancing
Other
None

Health Information. Does your child/children have any known medical conditions or precious injuries that may affect your child's participation in dance classes? *

Is your child currently taking any medications that we should be aware of? *

Does your child have any allergies that we should be aware of? *

Is there anything else you feel we should be aware of? *

By signing below, you are acknowledging the participation in dance activities involves a degree of risk, and you assume full responsibilty for any injuries or health conditions that may arise. SIGN BELOW *

You agree to release the EMDA and instructors from any liability for injuries or damages relating to participation in dance classes. By registering for EMDA you agree to abide by schools policies, and accept the terms and conditions. TYPE I AGREE BELOW *

Signed *

Send me a copy