Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Which Workshop are you registering for? *

Ages 10-14 ($30)

Ages 15+ ($100)

How will you be paying *

All e-transfers are to be made to kvitkadancers@gmail.com (password 'workshop') Cheques can be made payable to Kvitka Ukrainian School of Dance and mailed to 10265 167A St, Surrey BC. V4N 5H2

e-Transfer

Cheque by Mail

Media Release *

I hereby give consent for the registrant to be photographed or filmed for the use of Kvitka Ukrainian School of Dance

Yes

Liability *

I understand that Kvitka Ukrainian School of Dance is not responsible for any injuries that may occur during the workshop

Yes

Terms and Conditions *

I have read the terms and conditions

Yes