Name *

Student 1

First Name

Last Name

Date of birth

MM

DD

YYYY

Name

Student 2

First Name

Last Name

Date of birth

MM

DD

YYYY

Name

Student 3

First Name

Last Name

Date of birth

MM

DD

YYYY

Name

Student 4

First Name

Last Name

Date of birth

MM

DD

YYYY

Name - Parent/Caregiver 1 (student if over 18) *

(if student under 18)

First Name

Last Name

Mobile number - Parent/Caregiver 1 or Student if over 18 *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name - Parent/Caregiver 2

First Name

Last Name

Mobile number - Parent/Caregiver 2

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency contact phone number

(###)

###

####

Student 1 - Allergies or Medical Conditions?

YES

NO

Student 2 - Allergies or Medical Conditions?

YES

NO

Student 3 - Allergies or Medical Conditions?

YES

NO

Student 4 - Allergies or Medical Conditions?

YES

NO

Permission to take photographs/videos of student(s) for Greek Lyceum private use only eg. Concert Program, School Booklets, Costume tags, etc

YES

NO

Photographs and video footage of performances and classes are used on our website, social media accounts and advertising materials. We do not name the students who appear in these photographs or videos. Do you consent to the use of photograph and video footage of the student(s)? *

YES

NO

Does the student have dance experience from a previous Greek dance group or Greek school?

YES

NO

Name of person completing this form *

In lieu of signature

First Name

Last Name

Date *

MM

DD

YYYY