HIP HOP DANCE WORKSHOP

Hip Hop Dance Workshop

Youth's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
School*
Grade*
Parent or Guardian Name*
First Last
Parent/Guardian Cell Phone
Email*
Consent*
I hereby give my permission for my child to attend the REACH CYA Hip Hop Dance Workshop
I understand:

 The program will be supervised by Art in Motion Dance Instructors and REACH CYA staff.
 Transportation is not provided, youth Youth will need be transported to and from event.
REACH CYA does not provide any health/hospitalization insurance for my child.
In the event you cannot be reached in a medical emergency, you give REACH CYA staff authorization to secure proper
medical treatment, including taking your above named child to the nearest hospital. You release REACH CYA staff,
Board of Directors, designated drivers and all funding sources from any liability or legal
action.