Armour Dance Theatre: Summer 2023 (Goulds Elementary: 4th/5th Graders)

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Thank you for completing the registration form.
Completing this form does not guarantee registration. Site Directors will confirm registration based on availability and on a first come first serve basis. Thank you.

If you have any questions please call 786-824-7931 or email Ms. Naomi at Naomi@armourdance.org

Email *

Record my email address with my response

Primary Parent Email Address *

Primary Parent Name *

Child's Last Name *

Child's First Name *

Child's Middle Name *

Child's Date of Birth *

YYYY

Child's Gender *

Parent Phone Number *

Is this a cell phone number? (Please note that The Children’s Trust may contact you via postal mail, email and/or text to ask about your satisfaction with these services, and to make you aware of other Trust-funded programs, initiatives and events you may be interested in.)
*

Yes

What is Your Home Address

City *

Zip Code *

Child's Student ID (Miami-Dade Schools or Any Other) *

Name of Child's Current School *

What Grade Did Your Child Just Complete? (2022-2023 school year) *

Is your Child Proficient in English? *

Yes

What Other Languages are Spoken in Your Home? *

What is your child's Ethnicity? *

Haitian

HIspanic

Other

What is Your Child's Race? (Select One) *

Does your child have a condition or disability that will last more than a year? *

Yes

We want to get to know your child better so that we can provide the best possible experience in our programs. Please tell us more about your child…What are the main ways in which your child communicates? (Mark all that apply) *

Speaks and is easily understood

Speaks but is difficult to understand

Uses communication devices like pictures or a board

Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking

Uses sign language

Uses sounds that are not words like laughing, crying or grunting

What, if any, help does your child receive at this time? (Mark all that apply) *

Behavior Therapy or Services

Counseling For Emotional Concerns

Daily Medication (Not Including Vitamins)

Occupational Therapy (OT)

Physical Therapy

Special Education Services in School

Speech/Language Therapy

None of the above

Required

Does child have health insurance? (ex., private insurance, KidCare, Medicaid. If not, we may be able to help you find affordable coverage – call 211 or visitwww.thechildrenstrust.org/parents/health-connect/insurance.) *

Yes

If you marked “None of the above” on the previous question, please skip the next two questions and sign below. If you marked any other answer to the question above, please answer the remaining questions and sign below.

To support your child’s successful participation in this program, in what areas might s/he need extra assistance? *

No specific help needed

Holding a crayon/pencil, writing, using scissors or other fine motor tasks

Sports or physical activities like running or other gross motor tasks

Managing feelings and behavior

Academic, learning or reading activities

Adapting activities to take into account a visual or hearing impairment

Using assistive device(s) like a wheelchair, crutches, brace or walker

Personal services like help with feeding, toileting or changing clothes

Required

What conditions does your child have that are expected to last for a year or more? (Mark all that apply) *

Autism spectrum disorder

Developmental delay

Intellectual/developmental disability

Hearing impairment or deaf

Learning disability

Medical condition or illness

Physical disability or impairment

Problems with aggression or temper

Problems with attention and hyperactivity (ADHD)

Problems with depression or anxiety

Speech or language condition

Visual impairment or blind

None of the above

Required

Do any of the conditions marked above make it harder for your child to do things that other children of the same age can do? *

Yes

Please tell us anything else you think is important for us to know about your child. *

If you are interested in other services funded by The Children’s Trust, please call 211 or visit www.thechildrenstrust.org. For special needs resources for your child, visitwww.advocacynetwork.org or www.thechildrenstrust.org/cwd

I give my permission for this information to be submitted to The Children's Trust for program quality and evaluation purposes. The Children’s Trust provides funding for the program.

I give my permission for this information to be submitted to The Children's Trust for program quality and evaluation purposes. The Children’s Trust provides funding for the program. *

Yes

I confirm that the information above is true and agree to sign this registration form electronically. *

Yes

Type Full Name For Signature *

Armour Dance Theatre, INC. Release and Waiver of Liability if participant is under 18 years of age *

The undersigned is the parent or legal guardian of the child under the age of 18 named below (the “Participant”), who wishes to participate in the Armour Dance Theatre, Inc. dance program (the “Program”). In consideration of the Program allowing my child to participate, I hereby agree to indemnify Armour Dance Theatre, Inc., directors, officers, agents and employees and its owners, managers, promoters, lessees of premises used to conduct the Program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions, or instructions to engage in risk evaluation or loss control activities regarding the Program facility or events held at such facility and each of them, their directors, officers, agents, and employees (the “Releasees”) and to hold them harmless from any claim or demand on account of injury to or damage suffered by my child as a result of his or her participation, whether on the Program premises or elsewhere. I acknowledge it is my responsibility to deliver my child(ren) to the Program and to pick up my child(ren) promptly upon the scheduled conclusion of dance class(es). If competing or performing in an offsite event or venue, I assume responsibility for transportation of myself and/or my child(ren) to and from those events and/or venues.

The Program operates a youth dance program and the Participant wishes to participate in the Program. In consideration of being permitted to participate in any way in the Program indicated above and/or being permitted to enter for any purpose in any restricted area, I/WE agree as follows. List name of the participant *

1. I/WE fully understand and acknowledge that:(a) There are risks and dangers associated with participation in Program events and activities which could result in bodily injury partial and/or total disability, paralysis, and death. (b) The social and economic losses and/or damages, which could result from these risks and dangers described above, could be severe. (c) These risks and dangers may be caused by the action, inaction or negligence of the Participant or the action, inaction or negligence of others, including, but not limited to, the Releasees named above. (d) There may be other risks not known to us or are not reasonably foreseeable at his time.2. I/WE accept and assume such risks and responsibility for the losses and/or damages following such injury, disability, paralysis, or death, however, caused and whether caused in whole or in part by the negligence of the Releasees named above.3. I/WE agree to take appropriate precautions for my own safety and that of others when participating in the Program and further agree that, before participating I will inspect the facilities and equipment to be used and will if I believe anything is unsafe, immediately advise a staff member of that unsafe condition(s) and will refuse to participate.4. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE Armour Dance Theatre, Inc., including its Releasees from any and all claims, demands, damages, actions, causes of action of any kind or nature whatsoever which may arise in the future any injury, including but not limited to the death of the participant or damage to the property, arising out of or relating to the event(s) caused or alleged to be caused in whole or in part by the negligence of the Program or otherwise.5. EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release and waiver is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the event is conducted and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect.6. On behalf of the Participant, the undersigned executes this Waiver and Release. If despite this release, the Participant makes a claim against any of the releases, the undersigned will reimburse the Releasees for any money which they have paid to the Participant, or on his behalf, and hold them harmless. I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. Please electronically sign below

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