Holiday Dance Clinic Online registration is not complete until payment has been successfully processed. Enter Number of Children Attending*Please enter a number from 1 to 2.You can register two kids per form entry. If you need register more, you will need to complete the form again. Registration fee is $35 per child. Product Name*You can register two kids per form entry. If you need register more, you will need to complete the form again.Child's Name 1* First Last Child 1 Age (K - 5th Grade Only)* Child's Name 2 First Last Child 2 Age (K - 5th Grade Only) Please list any medical conditions/food allergies in this box - or type "none" if applicable.*Medical Treatment Authorization* Medical Treatment (Must Be Checked to Attend) In case of medical emergency, I hereby give permission for the staff of DPHS to seek medical treatment for my child and give permission to medical personnel to administer treatment, if deemed necessary. Check box to authorize. Signature* Type your first and last name in this box. This will serve as your "online" signature when the form is submitted.Parent/Guardian Name:* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Cell*Email* Enter Email Confirm Email Photo Release (Must be checked to attend)* I hereby authorize the Deer Park Independent School District to use or release any photograph of your participant made in conjunction with the instructional and/or extracurricular activities of the district and used to promote and/or publicize the educational program of the Deer Park Independent School District. This authorization is given without expectation of compensation or approval rights for the use or release of any such photograph. Check box to authorize. Internet Use (Must be checked to attend)* Should your child’s photo be chosen for publication, check this acknowledgment that gives your permission for the photo to be published on the DPISD Internet pages, social media pages associated with DPISD organization. Please note that the pictures of students will not be placed upon the Internet site until a signed release from the parent or guardian is on file. Check box to authorize. Total $0.00 You will be redirected to PayPal to complete payment when you submit this form.
