RHID Spring Registration
Please fill out form to register your dancer for the new dance year.
Email address *
Miss Stephanie Talks about RHID
First Name *
Your answer
Last Name *
Your answer
Gender *
Date of Birth *
Your answer
School Attending *
If school aged
Your answer
Our dancers after a "regular" show in April
Please select the class option for your child based on their age/experience and your location. *
Preferences do not guarantee placement. Level placement is based on experience and at the discretion of the instructors.
Required
Dancers from the RHID Company after a show in March 2017
Email address - Please type carefully *
Please enter an email address to receive the Rebel Heart newsletter and other important information. If you wish to be added to the RHID Facebook group, please enter the email address associated with your Facebook account here and check the box below.
Your answer
Email address - Secondary, or Student email *
Your answer
Parent Contact Information
If you are an adult applying for dance classes, feel free to skip parts of this section, as long as you enter at least one phone number and a current mailing address.
Mother's Full Name *
Your answer
Father's Full Name *
Your answer
Primary Phone Number *
Please use the following format: (000) 000-0000
Your answer
Mother's Work or Cell *
Please use the following format: (000) 000-0000
Your answer
Father's Work or Cell *
Please use the following format: (000) 000-0000
Your answer
Full Mailing Address *
Example: 123 Market Street, Camp Hill, PA 17011
Your answer
Medical and Insurance Information
Submitting medical information is required for all dancers.
Name of Insurance Company *
Your answer
Company Address *
Your answer
Name of Policyholder *
Your answer
Name of Secondary Policyholder
Your answer
Employer *
Your answer
Group Number *
Your answer
Identification Number *
Your answer
Phone Number for pre-authorization *
If required by your insurance plan
Your answer
Allergies *
Please list any food or prescription drug allergies.
Your answer
Medications *
Please list any medications that the student is currently taking.
Your answer
Conditions *
Please list any special physical or psychological conditions, past or present, of which RHID should be aware.
Your answer
Disclosure *
In the event I cannot be reached, I hereby give my permission to the management, faculty, staff and chaperones of the Rebel Heart Irish Dancers to authorize any emergency medical care that may be required by the above student during participation in classes, performances, or any related RHID events. This authorization extends throughout the current academic year or until the student is no longer enrolled at RHID, whichever comes first. I understand that I am responsible for any and all charges as a result of such care or medical treatment.
Required
Policy Overview
Please read carefully. This information and additional rules and policies are also available in our student handbook.
Tuition Policies *
Please check off each policy as you have read it. Each box must be checked in order to complete your registration.
Required
Tardy Policies *
Please check off each policy as you have read it. Each box must be checked in order to complete your registration.
Required
Dress Code *
To maintain the professional attitude of RHID, students should respect the dress code. Attire is considered a personal reflection of yourself and of the group. Not only is it essential for the safety of the dancer, but also to the discipline of the class and allows for better evaluation of technique.
Required
Costume Policies *
Please check off each policy as you have read it. Each box must be checked in order to complete your registration.
Required
Liability and Publicity Release
Please read carefully.
Liability Disclosure *
I am aware that dance training and the athletic exercises associated with it place unusual stress on the body and carry the risk of physical injury. On behalf of my child and myself (and if I am no longer a minor, on my own behalf), I assume the risk and agree that the Rebel Heart Irish Dancers shall not be liable in any way for injuries sustained during attendance at the studio or any of its related functions. I also understand that good dance training involves touching and adjustment of the student’s body by the instructor.
Required
Publicity Release *
I hereby authorize the Rebel Heart Irish Dancers to record the student’s picture and voice on photographs, films, and tapes, to edit these recordings at its discretion, and to incorporate these recordings into movie and sound films on tapes, radio, or television broadcast programs. I also give my permission for RHID to use and license others to use these materials in any manner or media whatsoever. RHID is permitted to use these materials for publicity, advertising and sales promotion and to use the student’s name, likeness and voice and biographic or other information in connection with them. I acknowledge that no promises of compensation were made by RHID for such use.
Digital Signature *
By typing my initials below, I am stating that I have read and understand the above policies.
Your answer
You're almost done!
NEW MEBERS ONLY: How did you hear about us?
Please let us know! If you were referred by a friend please mention that here so we can credit them.
Your answer
Have you filled out everything carefully? *
Make sure the information you've entered is correct!
Required
Master Andrew talks about The benefits of Dance for BOYS!
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