Arkansas Dance Network
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REGISTER NOW!
(SEE FORM BELOW)
REGISTRATION FORM - ADN Dance Workshop
with Rhonda Miller, March 2, 2015, 6:00-7:30pm
*
Indicates required field
Participant Name
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First
Last
Address
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Line 1
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City
State
Zip Code
Country
Phone Number
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Alternate Phone Number
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Emergency Contact Name
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First
Last
Emergency Contact Phone Number
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If under 18, Parent/Guardian's Name
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First
Last
Participant's Birthdate: Month
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February
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Day
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1965 or earlier
Email
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If under 18, does this participant have the permission of his/her parent/legal guardian to participate in this workshop?
*
Yes
No
N/A (Participant is 18 years or older)
Liability Release
By submitting this registration, I agree to release North Little Rock High School, Arkansas Dance Network, its teachers and volunteers from any and all claims in the event of personal injury or property loss sustained during this event.
*
By checking this box I hereby certify that I have read, understood, and agreed to the above Liability Release.
Photo/Video Consent & Release
I hereby grant to Arkansas Dance Network, its affiliates, subsidiaries, agents, and others on its behalf, the right to use (display, license, publish, etc.) photographs and/or video (the "Images" made of me from the 2015 Dance Workshop in any manner or media (whether now existing or hereafter invented) including any online service for purposes of advertising, promoting or publicizing Arkansas Dance Network and/or its affiliates, its services, programs and events.
I acknowledge and agree that I shall have no right of approval, no claim to compensation and no claim (including without limitation) to claims based on invasion of privacy, defamation, or right of publicity arising our of any use or alteration of the Images in any composite form.
The images taken of me were taken without any prior promise of payment or other benefit, and without any expectation of payment or benefit in return for giving my permission.
*
By checking this box I hereby certify that I have read, understood, and agreed to the above Photo/Video Consent & Release.
Submit