Waiver and Registration Form Pender- Keady Academy of Irish Dancing Registration and Waiver Form 2008 - 2009 Child’s Name: _______________________________________________ Parent’s Name: ________________________________________________ Street: _________________________ Town: ______________ Zip: ______ Home Phone: ___________________________________________ Cell Phone: _____________________________________________ _____Please check here if you would like to be included in our PKA directory How did you hear about us? _____________________________________ Emergency Contact Name: __________ Emer. Contact Phone: __________ *E-Mail Address: _______________________________________________ (must include e-mail address) Child’s Date of Birth: ___________________________________________ Child’s Allergies: ______________________Asthmatic? Yes____ No____ Other Medical Conditions: _______________________________________ Class Day, Time, and Location you are registering for: I acknowledge that this activity involves exertion and carries with it the potential for injury. I hereby agree to waive the right to take legal action against the Pender-Keady Academy, Fine Arts Conservatory of New Canaan, Greenwich YMCA, Norwalk YMCA, Darien YWCA, Erin Pender-LeVine, Kathleen Keady, and/or any affiliates and associates for injuries incurred on these premises. It is understood and agreed that the participant is physically fit and prepared for participation in the activities which will be undertaken, and that the participant has not been advised by any doctor or other medical person that participation in these activities should be avoided and/or limited. Parent/Guardian Signature: ____________________________________ Date: ________________________________________________________ *** NO REGISTRATION CAN BE ACCEPTED WITHOUT $40 REGISTRATION FEE PER DANCER ***