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)