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ROAD to Zambia Foundation

Home
About Us
Team
Join The Team
Student Registration
Gallery
Media
Contact Us

Student Registration

R.O.A.D TO ZAMBIA FOUNDATION

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

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Select

School Name *

Grade

STUDENT INFORMATION

Student’s Name *

Birthday

Age

Where do You live? *

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:

Cell Phone:

Email *

Place of Employment: *

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

Name *

Relationship to Child *

Phone *

How did you hear about our program? *

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 frant 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 hereby 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:

Select a 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

Select a 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):

For Non-Students

TUITION INFORMATION:

TUITION IS FREE FOR ALL PARTICIPATING SCHOOLS STUDENTS. IF YOU ARE NOT A STUDENT OF AN PARTICIPATING SCHOOL, PLEASE ADHERE TO THE PAYMENT INFORMATION OUTLINED BELOW OTHER OPTIONS MAY BE AVAILABLE.

PAYMENT INFORMATION:

Payment Plans:
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

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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:

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: *

Your Signature

Select a date

RELATIONSHIP TO STUDENT

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

I am a

Beginner
Intermediate
Advance

Monthly Payment For Beginner

Monthly Payment For Intermediate

Monthly Payment For Advance

ROAD to Zambia Foundation

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Cleveland, OH, USA 44101
+1 702 559 4786
road2zambiafoundation@gmail.com

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ROAD to Zambia Foundation

ROAD to Zambia Foundation

Student Registration

R.O.A.D TO ZAMBIA FOUNDATION

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

STUDENT INFORMATION

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

Work Phone:

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

MEDICAL & MEDIA RELEASE AND AUTHORIZATION

EMERGENCY INFORMATION

For Non-Students

TUITION INFORMATION:

TUITION IS FREE FOR ALL PARTICIPATING SCHOOLS STUDENTS. IF YOU ARE NOT A STUDENT OF AN PARTICIPATING SCHOOL, PLEASE ADHERE TO THE PAYMENT INFORMATION OUTLINED BELOW OTHER OPTIONS MAY BE AVAILABLE.

PAYMENT INFORMATION:

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

ROAD to Zambia Foundation

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