SDW Community Pop-Up Class Registration

Step 1 of 3

Thank you for registering for a SDW Community Pop-up class

This form will collect student personal identification and contact information; policy, media, and liability releases; and community pop-up class selections. For any questions regarding registration, contact the School Administrator at school@dancingwheels.org or call (216) 432-0306.

Student Information

Name(Required)

First Last

Date of Birth(Required)

Age

Pronouns

he, she, they, xie, (other)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student is below 18 years of age(Required)

Yes

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.

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.