EmailMe Form - Zumba® with Luci Registration Form

Child's Name *
First Last
Gender *
Boy
Girl
Age *
I am registering for *
Friday class
Parent / Guardian Information
Please enter parent or legal guardian information here
Name *
First Last
Phone *
Email *
Address

Street Address City State / Province / Region Postal / Zip Code
Emergency contact details
Name *
First Last
Phone *
Relationship to child *
Information about your child
(please be as detailed as possible)
Activities your child cannot participate in *
Medical condition / allergies / permanent injury / disability *
Regular medication the child takes *
Terms & Conditions
Dance and fitness classes can involve risk of injury. While Zumba® with Luci takes all reasonable care in conduct of its classes, it accepts no responsibility for injury or loss caused during Zumba® Kids classes.
Acknowledgement *
By ticking this box, I acknowledge that I have read and accept above terms and conditions.
Consent to use photo / video
I understand that my child might be in a photo or video taken during the class, and give Zumba® with Luci permission to use either for marketing purposes. I understand that that I will not be entitled to any compensation or royalties arising from the use of photos and/or videos as promotional material.
*
Agree
Do not agree