All dancers registered for a class or camp at PopRox must have this form filled out by a legal guardian before their first class or summer camp at PopRox.

Dancer’s Name *

First Name

Last Name

Dancer’s Pronouns *

What pronouns does your dancer use?

Dancer’s Age *

Dancer’s D.O.B *

YYYY

My dancer is registered for the following: *

Summer Camp

K-Pop Summer Series

Kid or Teen Class

My dancer is attending a class/camp at: *

PopRox U-District

PopRox Capitol Hill

During the week of:

Campers Only:

Is there any important information we need to know about your dancer? *

Allergies, dietary resrtrictsions, accessibility needs, etc.

What is your camper’s shirt size?

Campers Only:

Primary Contact *

First Name

Last Name

Relationship to Dancer *

Phone # *

Primary Contact

(###)

###

####

Email *

Primary Contact

Emergency Contact *

First Name

Last Name

Relationship to Dancer *

Phone # *

Emergency Contact

(###)

###

####

In the case of a minor injury, please contact: *

Please list full name, relationship, and phone #

In the case of an emergency, please contact: *

Please list full name, relationship, and phone #

The following people are authorized to pick up my dancer: *

Please share the names and contact information of those authorized to pick up your dancer:

Do you give permission for your teen to leave without a parent/guardian signing them out? *

YES

N/A

Do you give PopRox permission to use your dancer’s image in future marketing materials? *

YES

LIABILITY AGREEMENT *

I hereby authorize representative of PopRox Dance LLC, including employees, directors, or identified volunteers, to serveas agents for my child to consent to any emergency medical care, including x-ray exam, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is rendered under the general or specific supervision of any licensed physician or surgeon on the medical staff of any hospital licensed by the State of Washington whether such diagnosis or treatment is rendered at the office of said physician or at said hospital or some other site. I also understand and agree that PopRox Dance shall not be held responsible for any injuries, damage, or personal loss which might occur while attending or participating in any PopRox function. The authorization shall remain valid for the duration of your child’s registration with PopRox Dance. By registering for class, you agree to comply with our terms of service and policies listed on the following pages: -www.poproxdance.com/booking-terms -www.poproxdance.com/terms-service -www.poproxdance.com/privacy-policy -www.poproxdance.com/anti-harassmen

Date: *

YYYY

Thank you!

UNIVERSITY DISTRICT
4571 11th Ave NE
Seattle, WA 98105
CALL or TEXT 206.902.7688

CAPITOL HILL
Chophouse Row
1429 12th Ave
Seattle, WA 98122
CALL or TEXT 206.316.6031

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