DW Community Day DW Community Day Registration Step 1 of 3 33% Thank you for registering for DW Community Day! This form will collect student personal identification and contact information; policy, media, and liability releases; and trial class selections. For any questions regarding registration, contact the School Administrator at school@dancingwheels.org or call (216) 432-0306. Student InformationName(Required) First Last Date of Birth(Required) AgePronouns he, she, they, xie, (other)Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Student is below 18 years of age(Required) Yes No Parent/Guardian Name(Required) First Last Parent/Guardian Phone(Required)Parent/Guardian Email(Required) Emergency Contact Name(Required) First Last Emergency Contact Phone(Required)Accessibility Needs Dancing Wheels studios are located on the first, ground-level floor and are wheelchair accessible. Are there any other accommodations that you/the participant need? Do you/the participant have any support requirements, such as people, tools, or technology that you/they would like integrated into the activity.Name of Student's School Grade in School Liability Waiver I, being aware of my own/my student’s health and physical condition, and having knowledge that my/my student’s participation in any physical activity may be injurious, am acknowledging this release from liability for accidental injury or illness which may be incurred as a result of participating in this physical activity. I hereby assume all risks connected therewith and consent to my/my student’s participation in this program. In the event that medical care or treatment is required, I agree to be financially responsible for any costs incurred as a result. I acknowledge that I have carefully read this Liability Waiver and Release Form and fully understand that it is a release of liability. I agree to give up any right that I may otherwise have to bring a legal action against the Dancing Wheels Company & School and their affiliates for negligence or any other personal injury or property damage.Release of Liability(Required) I hereby agree to the above Release of Liability for the Dancing Wheels Company & School.Check the box to accept the terms of liability.Media Release I hereby grant permission to the Dancing Wheels Company & School to use photographs and/or video of me/my student taken at all Dancing Wheels Company & School classes, performances, and events in publications, news releases, online, and in other communications related to the mission of the organization. I understand that my/my student’s image may be used in video recordings of virtual classes, and that these classes will remain the property of the Dancing Wheels Company & School henceforth. The Dancing Wheels Company & School may then use these recordings at any future time as they deem appropriate in providing future virtual programming or promotional materials.Media Release Agreement(Required) I hereby agree to the above Media Release for the Dancing Wheels Company & School. I do not release my/my student’s image for use by the Dancing Wheels Company & School. Select the classes for which you wish to participate in on DW Community Day Saturday, September 14, 2024.Select Your Class(es)(Required) Youth Combo Class – 10:00am–11:00am Contemporary – 10:00am–11:00am Open DW Community Class – 11:00am–12:00pm Ballet – 11:00am–12:00pm Jazz Funk – 12:00pm–1:00pm Wheelchair Technique – 1:00pm–2:00pm Hip Hop – 1:00pm–2:00pm Capoeira – 2:00pm–3:00pm Conditioning – 2:00pm–3:00pm DW Community Day classes are on Saturday, September 14, 2024.I would like to participate:(Required) In-person at Dancing Wheels Online via Zoom
