Dnaga REGISTRATION FORM

dNaga REGISTRATION FORM GIRL Project

dNaga office address: 473 Hudson St. Oakland, CA 94618 www.dnaga.org ~ [email protected] ~ (510) 420-0920 GIRL Project workshop address: Eastside Arts Alliance, 2277 International Blvd., Oakland, CA 94606

PLEASE PRINT CLEARLY Student’s Name______DOB______/______/______Student’s cell phone number______Student’s email address______

Parent’s Name______Address ______City ______Zip Code______Phone (H) ______(W) ______(C) ______Email ______What language do you speak inside the home? ______Do you require an interpreter? (Y/N) Do you prefer to be contacted via email ____ or telephone ____? We never sell or share your personal information with outside groups.

Parent/Caregiver’s Name ______Address ______City ______Zip Code ______Phone (H) ______(W) ______(C) ______Email ______What language do you speak inside the home? ______Do you require an interpreter? (Y/N) Do you prefer to be contacted via email ____ or telephone ____? We never sell or share your personal information with outside groups.

Emergency Contact (other than listed above)______Phone #______Relationship______

Student Information: Current Academic School:______Allergies:______Current Medications:______Students Sizes: Shoe______Shirt______Tights______

Image Release dNaga strives to share images that reflect our programming and dance community. We may take photographs and video/audio recordings during the workshop and performance for inclusion in a variety of media. We will not share your daughter’s full name or school with the public.

Please initial and sign below: ___ I GRANT PERMISSION to dNaga to publish, reproduce and distribute photographs, electronic images or video of my daughter. This permission extends to printed materials, broadcast media and the dNaga website. Workshop Schedule The workshop will take place from 9am to 3pm Monday through Friday, primarily at EastSide Arts Alliance (2277 International Blvd, Oakland, CA 94606). Some workshop sessions will take place at other nearby locations: at The Annex (2277 International Blvd.) and at SOL Garden (1236 23rd Ave). Pick up and drop off each day will be at EastSide Arts Alliance, where doors will open at 8:30am and close at 4:00pm. If this schedule is problematic for your family, please let us know, as before and after care may be available.

How did you hear about the GIRL Project? ______

Will the GIRL Project workshop schedule be a problem for your family? (Y/N)

If yes, will you need before or after care? (Y/N) ______

___ I GRANT PERMISSION for my daughter to walk home from the GIRL Project workshop

___ I GRANT PERMISSION for my daughter to be picked up by someone other than the parents/caregivers previously listed on this form. Name ______Phone ______

I, ______, the parent/guardian responsible for the student, have read the entirety of this registration form and approve of my child’s participation in the GIRL Project. I understand that this workshop includes physical practices such as dance and bicycling, and I agree to release dNaga and partnering organizations from any liability resulting from the natural practice of these activities.

Signature ______Date ______

Please use the space below for any questions, comments, or concerns: