Lemonade Crunchy Ice Registration Form::2021
Wednesdays 4-5:30pm Feb 17-May 22
Via Zoom
Contact us at dnagagirlproject@gmail.com
Zoom link will be sent to eligible participants via email address and phone number provided
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Email *
Student First Name *
Student Last Name *
Student Nickname
Phone # *
Date of Birth *
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DD
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Student Mailing Address *
Is this a secure mailing address for receiving supplies?
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If not, is there and alternative that you would prefer?
(1) Parents/ Caregivers Names *
(1) Parents/Caregivers Phone #'s *
(1) Parents/ Caregivers Email Address'
Language spoken at home
Do you require an interpreter?
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How do you prefer to be contacted?
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Emergency Contact Name
Emergency Contact Phone #
Student Information: Current Academic School: *
Student Information: Dietary restrictions *
Student Information: Shirt size *
Student Information: Pants Size *
Student Information: Shoe size *
Image Release dNaga strives to share images that reflect our programming and dance community. We may take photographs and video/audio recordings during the workshop and performance for inclusion in a variety of media. We will not share your daughter’s full name or school with the public. Do we have permission to share images of your child participating in Girl Project programming? *
Please initial and sign below: I GRANT PERMISSION to dNaga to publish, reproduce and distribute photographs, electronic images or video of my daughter. This permission extends to printed materials, broadcast media and the dNaga website. *
A copy of your responses will be emailed to the address you provided.
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