CHABAN UKRAINIAN DANCE GROUP (rev Aug2009)

2009/10 REGISTRATION: Ukercize / Alumni

Please PRINT. Please complete ALL sections.

NAME OF DANCER: __________________________________________________________________

DANCER E-MAIL: ________________________________________________________ (please PRINT)

ADDRESS: _____________________________________________________POSTAL CODE ________

HOME PHONE: _______________ CELL PHONE: _______________ FAX NUMBER:_______________

ALTERNATE CONTACT, IN CASE OF AN EMERGENCY, OTHER THAN HOME PHONE NUMBER: Name:____________________________________________________ Phone:_____________________

DANCER’S AGE: ______ DATE OF BIRTH:(D)_____ (M) _____ (Y) _____ GENDER: ___________

Previous dance experience? YES ____ NO ____

If YES, what kind, and the number of years: _________________________________________________

_____________________________________________________________________________________

Do you have ANY medical disabilities or handicaps that will affect your ability to dance and that the teacher should know about? YES ___ NO ___ Do you have any ALLERGIES? YES ____ NO ____

If YES, please explain:_____________________________________________________________________

PHOTO CONSENT: photos of dancers/volunteers are often taken during Chaban & related activities. Please check if you do NOT ___ (and initial ______) wish to have dancer/volunteer picture, as taken by Chaban, used for display or advertising purposes. Note that checking “NOT” means the individual will be excluded from group photos.

I, the dancer, understand that the Chaban Ukrainian Dance Group, its affiliated organization, the League of Ukrainian Canadians, or any other rehearsal/performance location will not be held responsible for any mishap which may occur to myself/registrant at dance rehearsals or performances or on his/her/my way to/from a dance rehearsal, activity or performance. DATE: ___________________

Signature of Dancer (aged 18 or older) ____________________________________________________

How did you find out about Registration? Posters___ The Key ___ Newspaper ___ Chaban Memo ____

Other ____________________________________________________

I, the dancer, agree to act in a responsible manner and will proudly represent the Chaban Ukrainian Dance Group to the best of my ability. DATE: _____________________________

Signature of Dancer: ___________________________________________________________________

I, the dancer, have read the Compulsory Dancer Dress Code and agree to adhere to the Dress Code in the interest of safety and to further advance my dance skills. DATE: _____________________________

Signature of Dancer: ___________________________________________________________________

Amount Paid $______________ for _________Dancer(s). CASH:__________ CHEQUE:___________

If FAMILY or MULTIPLE payment, please list names of other dancers:___________________________

_____________________________________________________________________________________

TELLER’S NAME:___________________ RECEIPT #: __________DATE: ______________________

One-time Costume Damage Deposit ($25.00): Amount Paid $ _____. CASH:______ CHEQUE #:______ Receipt #:______

ALUMNI / UKERCIZE: Dancing: Yes _____ No _____

Volunteer opportunities (circle those that interest you):

CONCERT: Acting; Props; Backstage other;

Other: ________________________________________________________________________________________________