Student's Name *
Student's Name
Birth Date
Birth Date
Day and month please, year if you like!
eg. Jane Blogs - Mother
If you do not have a cellphone please put another contact number here. This will be used to contact you for any last minute changes in classes and other Nia 'emergencies'!
The information you disclose on this form will remain private and will not be shared with anybody except in a health/medical emergency that may result from your participation in a Nia class. Its intended purpose is to provide valuable information to your Nia teacher so that they may give the best care to you in an emergency.
Waiver Release
To the best of my knowledge the information I have provided on this form is accurate. My child's participation in class is voluntary and I declare myself and myself only to be responsible for the health and safety of my child while he/she is participating in FreeDance classes. I release Nicola Chung, the teacher, from any responsibility for any consequences that may arise from my child's participation in FreeDance classes. *
By choosing 'Yes, I agree' below, you acknowledge that you understand the above and are in agreement and will act as your signature to the waiver.
Date *