Registration Form

NAMYANKA Performing Arts Training Center
Liturgical Dance Academy
2022-2023 Season
Registration Form
(please print clearly)
NAME_________________________________________________________________________
ADDRESS________________________________________ZIP CODE_________STATE________
PHONE___________________________EMAIL:_______________________________________
DATE OF BIRTH___________________________________________AGE___________________
EMERGENCY CONTACT
Name_____________________________________________Relationship_________________
Address___________________________________________Phone_______________________
Church Affiliation:___________________________________Pastor______________________
Current Ministry Participation_____________________________________________________
PERFORMING ARTS EXPERIENCE:____African _____Ballet _____Dunham ____Modern____Tap____Musical Instrument ____Vocals ____Drama ____Other__________
HEALTH HISTORY
___Asthma _____Heart Problems ______Hypertension _____Diabetes _____Arthritis
___ADHD _____Other _______________________________________________________
Prescribed Medications__________________________________________________________
NAMYANKA PARTICIPATION
____Ensemble (Thursday, Saturday, Rehearsal
____Community Membership Class (Thursday and Saturday)
Liability Waiver:
I understand that Namyanka PATC and Govans UM Church will not be held liable for any injuries and/or illness that I may experience while in class, performing or on the property of Govans United Methodist Church.
I have read and agree to abide by all of the guidelines, policies and procedures that are set forth by the Board and Directors of Namyanka Performing Arts Training Center.
Participant’s Signature____________________________________________Date_________
Parent/Guardian Signature______________________________________________________
(if under age 18)