Student Registration

R.O.A.D TO ZAMBIA FOUNDATION

SUMMER CAMP

R.O.A.D (Reaching Out and Dance)

STUDENT SUMMER CAMP REGISTRATION FORM

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I am a

School Name

Grade

STUDENT INFORMATION

Student’s Name

Birth Date

Age

Home Address

Address Line 1

City

State

Zip Code

Home Phone Number

PARENT(S)/GUARDIAN(S) RESIDING WITH CHILD

Name

Relationship to Child

Cell Phone:

Work Phone

Place of Employment:

ALL PERSONS AUTHORIZED TO PICK UP CHILD

Name

Relationship to Child

Phone

2

Name

Relationship to Child

Phone

MEDIA RELEASE AND AUTHORIZATION

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs,movies or video tapes or the Student named above. I also grant to the right to edit ,use, and reuse said products including use in print, on the internet, and all other forms of media. I also here by release R.O.A.D To ZAMBIA FOUNDATION and its agents, employees and affiliates from all claims,demands,and liabilities whatsoever in connection with the above.

SIGNATURE OF PARENT/GUARDIAN:

Date

MEDICAL & MEDIA RELEASE AND AUTHORIZATION

Name

Indicated in the space below are any health problems or conditions of which R.O.A.D TO ZAMBIA FOUNDATION should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.).

I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and my child, knowingly and voluntarily accept that risk.

MEDICAL & MEDIA RELEASE AND AUTHORIZATION

I, the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release R.O.A.D TO ZAMBIA FOUNDATION and its staff from any and all claims or damages of any kind arising out of my child's participation in the exercise and/or dance program of.

MEDICAL & MEDIA RELEASE AND AUTHORIZATION

I further certify that the aforementioned student is in proper physical condition to participate in the exercise/dance program and that he/she has been examined by a licensed physician and found to be in proper physical condition to participate in said program.

MEDICAL & MEDIA RELEASE AND AUTHORIZATION

I, the undersigned, do hereby authorize R.O.A.D TO ZAMBIA FOUNDATION. staff (teachers or administrators employed by R.O.A.D TO ZAMBIA FOUNDATION) to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorize the treating physician to provide such emergency medical services.

MEDICAL & MEDIA RELEASE AND AUTHORIZATION

I understand that I am responsible for any medical expenses and that the absence of health insurance does not make R.O.A.D TO ZAMBIA FOUNDATION responsible for payment of medical expenses. This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect for one year from the date signed below

SIGNATURE OF PARENT/GUARDIAN

Date

WITNESS (Must be at least 18 years of age):

EMERGENCY INFORMATION

Physician

Hospital Preference

Allergies (food, medicine, etc)

Additional Information/Comments (i.e. blood transfusions, etc):

TUITION INFORMATION:

THIS FORM IS SPECIFICALLY FOR SUMMER CAMP ONLY, PLEASE SEE REGISTRATION FORM FOR REGULAR SEASON.

PAYMENT INFORMATION :

Plan A: Pay in full.
Plan B: Automatic bank account debit on the first of each month. Provide a voided check (no check cards or deposit slips).
Plan C: Automatic credit card payment on the first of each month.
Registration Fees: New Student: $35. Returning Student: $25

Third Family Member (parents/siblings): $

Student Registered prior to August 2004: $0. Family Maximum: $70.

I have chosen payment plan:

Plan A
Plan B
Plan c

Registration Fee:

Monthly Tuition :

TUITION INFORMATION

I understand that one make-up class is permitted for each class my child misses. Make-up classes must be taken within 30 days of the missed class(es). I also understand that all fees paid are nonrefundable and nontransferable. The parent or guardian is responsible for notifying, in writing to our email address road.danceprogram@gmail.com of any change to the credit card or checking account. The returned check/declined card fee is $35. Should this provision have to be enforced by legal means, the undersigned person(s) is responsible for payment, as liquidated damages, the costs of collection, plus interest at the legal rate and reasonable attorney’s fees as determined by the Court or 15% of the amount collected failing such determination.

PERSON RESPONSIBLE FOR PAYMENT:

Print Name

Signature

Date

Relationship To Student

Witness (Must be at least 18 years of age)

Download Road summer instructing plan

ROAD to Zambia Foundation

ROAD to Zambia Foundation

Student Registration

R.O.A.D TO ZAMBIA FOUNDATION

SUMMER CAMP

R.O.A.D (Reaching Out and Dance)

STUDENT SUMMER CAMP REGISTRATION FORM

STUDENT INFORMATION

PARENT(S)/GUARDIAN(S) RESIDING WITH CHILD

ALL PERSONS AUTHORIZED TO PICK UP CHILD

2

MEDICAL & MEDIA RELEASE AND AUTHORIZATION

EMERGENCY INFORMATION

TUITION INFORMATION:

PAYMENT INFORMATION :

Student Registered prior to August 2004: $0. Family Maximum: $70.

PERSON RESPONSIBLE FOR PAYMENT:

ROAD to Zambia Foundation

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