JetBlack Dance Academy Registration Form

JetBlack Dance Academy

Registration Form
CEO: Yosha Gilkes

Chair: Michelle Gilkes

Secretary: Sharon Crithlow

Assistant Secretary: Asante Crithlow

Treasurer: Selwyn Holder
WELCOME MEMBERSHIP FORM
Jetblack Dance Academy would like to welcome you as a member and we strive to make your time here an enjoyable and fulfilling one. All prospective members of Jetblack Dance Academy are required to complete the registration form.

All details will be kept in a secure database file and access restricted to authorised officer.

If you are under 18 your parent or guardian must complete the information where indicated and sign the boxes of page 2 and 3 on the form before it is returned. Please make sure all parts are completed fully on the form, any gaps may prevent your child form participating.

We will also use this information to ensure you are kept informed about JBDA news and events
CLUB MEMBERSHIP DETAILS
Name: Full name or the member*
Address (Home) including postcode*
Daytime number of parent/carer*
Date of birth (of member)*

MonthDayYear
Date
Mobile (of member if 16 or over)

Area CodePhone Number
Email (of member if aged 16 or over)
example@example.com
NB: Any individual text or email to member age 14+ will be duplicated to parents carer and club safeguarding officer.
AFFILATION AND MEMBERSHIP FEES
SUBS & MEMBERSHIP

£8 per Dance Class£20 Monthly Dance Class£35 Monthly Dance Class£5 DJing & Music Production£20 Insurance Fee (when you join and recurring every September)
Ethnicity
Medical information- Mandatory

To be completed by the Parent/Carer

Please detail below any important information that our teachers/management should be aware of.
As far as you know are you allergic to any Medication, Please state
Are you taking any medication, if yes for what reason
Do you have any long term illnesses or injuries
DeafPhysical disabilityVisually impairedHearing impairedMultiple disabilityLearning disability
If yes to any of the above please add any addition information:
EMERGENCY CONTACT DETAIL-Mandatory

To be completed by the parent/carer

Please insert the information below to indicate the person(s) who should be contacted in event of an incident/accident
Contact Name
Relationship To Member
Emergency Phone Number
Doctors Name
Surgery
Doctors Phone Number
Declaration: I consider my son/daughter to be physically fit and capable of full participation in the activities of the dance school and agree to notify Jet Black Dance Academy of any changes to the medication information provided. I understand in the event of injury or illness, all reasonable steps will be taken to contact me and to deal with the injury or illness at the time. Furthermore in the event of injury/illness to my son/daughter I give permission to the dance teachers appointed by jet black dance academy to obtain emergency medical treatment.
Name of parent/carer*
Signature*

Clear
Date*

MonthDayYear
Date
I am signing this form and I confirm receipt of the codes of conduct for students and parent/carers and agree to be bound by the codes of conduct and respect all fellow dancer regardless of age, gender, ability, race, cultural background, religious beliefs or sexual identity.
Name of young person*
Signature*

Clear
Date*

MonthDayYear
Date
TRANSPORTATION / PHOTOGRAPHING / VIDEO CONSENT
It is a requirement of Jet Black Dance Academy policy that parent/legal guardian(s) consent is provided for transportation and photography.
I blanks* give consent for blank* to be included in any promotional material for Jet Black Dance Academy also to be Transported.
Signature*

Clear
Relationship*
Date*

MonthDayYear
Date
Should be Empty:

JetBlack Dance Academy

WELCOME MEMBERSHIP FORM

CLUB MEMBERSHIP DETAILS

AFFILATION AND MEMBERSHIP FEES

TRANSPORTATION / PHOTOGRAPHING / VIDEO CONSENT