Child Information

Childs Name and Date of Birth

Childs Phone Number

Has your child participated in dance, cheer, or any performance activities with another organization?

Please provide details and reason for leaving:

Medical Information

Physician:

Physician's Phone Number:

Insurance Provider:

Policy Number

Allergies/ Medical Concerns:

Medications

Are you enrolling more than one child?

Second Childs Name and Date of Birth

Second Childs Phone Number

Second Child | Has your child participated in dance, cheer, or any performance activities with another organization?

Second child | Please provide details and reason for leaving:

Second Childs Physician:

Second Childs Physician's Number:

Seconds Child Insurance Provider:

Second Childs Policy Number:

Second Child | Allergies/ Medical Concerns:

Second Childs Medications:

Parent/ Guardian Information

Parent/ Guardian First Name

Parent/ Guardian Last Name

Email *

Phone *

Address

Street Address

City

State

Country

Postal code

Emergency Contact (if different from parent):

Authorized Pick-Up Individuals

Liability and Indemnification Agreement

By checking this box, I agree to release, defend, indemnify, and hold harmless Platinum Divaz Dance Company, its staff, and volunteers from all liability arising from, or related to, my child’s participation in any event or practice.

Media Release

By checking this box, I understand that Platinum Divaz Dance Company may photograph, film, tape, or record my child and/or myself for publicity, documentation, or ticket sales purposes. By signing this release, I give full permission and waive all copyright and future considerations related to the use

of these media.

Dance Team Participation Agreement

By checking this box, I agree, I, the parent/guardian of the above-named child, confirm that I have read the Platinum Divaz Handbook and understand all the requirements for my child’s participation. I agree to abide by all policies outlined in the Dance Team Code of Conduct and understand the consequences for non-compliance, including the potential forfeiture of my child’s place on the team.

I grant permission for my child to attend field trips and events organized by Platinum Divaz Dance Company. I release Platinum Divaz Dance Company, event venues, and staff from any liability in the event of an accident before, during, or after these activities.

I am aware that this is a team effort and am committed to helping with team activities when possible. I also agree to attend parent meetings or ensure that someone attends on my behalf.

Emergency Medical Authorization

By checking this box, I agree that in case of emergency, I authorize Platinum Divaz staff to act on my behalf and make medical decisions for my child if neither parent/guardian can be reached. This includes authorization for

medical care by an attending physician or paramedics.