Your email Your child's name Date of birth Gender FemaleMalePrefer not to sayOther Current Full Address Phone Number Allergies/Medical Conditions Parent Contact 1: (Name, Phone #, Email, Relationship) Parent Contact 2: (Name, Phone #, Email, Relationship) Emergency Contact (Not residing with you... Name, Phone #, Relationship) ) Do you give the D'LYFE Staff authority to take initial steps to secure medical advice/service if your son/daughter requires medical treatment? If you do not give authority, the emergency contact will be contacted before seeking medical assistance. I give authorityI do not give authorityOther Program Selection Happy FeetJuniorsInt. Division 1Int. Division 2DrummingOther Optional Dance Attire available for Pre-Order/Purchase 1 for $15 D'LYFE T-SHIRT2 for $25 D'LYFE T-SHIRT$30 FOR XS/S FOLK SKIRT$35 FOR M/LG FOLK SKIRT$20 SUPPORTER T-SHIRT - D'LYFE CREW$20 SUPPORTER T-SHIRT - D'LYFE MOMOther Specify Other Shirt size: (ie. 5T, 13/14, Adult M) I give permission to have my child recorded or photographed by D'LYFE Staff for the purpose of learning or teaching materials. I consentI do not consent I give permission to have my child recorded or photographed by D'LYFE Staff for the purpose of promotional use for D'LYFE Dance Company I consentI do not consent I give permission to have my child photographed or recorded by the media and/or individually interviewed related to their participation in the D'LYFE program. I consentI do not consent Additional: Board Member Nomination I wish to declare my candidacy for an elected position on the Board at the next AGM By checking the box below, you agree and confirm that you, (Please checkbox before signing) I have read and understand the rules of conduct for participants and will assist your child/youth to abide by to them as well as the directions of the instructions at all timesare aware of the dance requirements and will respect the established standard; and(*I) release D'LYFE Dance Company affiliates from any and all claims and causes of actions that I or my representatives have or may have in the future for personal injury or property damage occurring to my son/daughter, arising out of participation in dance program activities. Name of Parent/Guardian (In place of signature) Date
