Download Greek Orthodox Church - Byzantio Greek Dance

Permission Slip for the 2016-2017 Dance Year
My child/children __________________________________________________________ has/have my
permission to participate in the Byzantio dance program. I indemnify the directors of the dance program and
Saints Katherine Greek Orthodox Church from any liability or hazard that may arise from but not limited to
dance practice, performances, or transportation.
I authorize the Byzantio Greek Dance and Cultural Arts Program to use my child’s likeness on the web, social
media, or still photograph production that will be produced by and available to the public from the Program.
The Byzantio Greek Dance and Cultural Arts Program is not responsible for and cannot control the use of a
child’s likeness on the web, social media, or still photography produced by others.
I __________________________________ have read and understand the Byzantio Greek Dance and Cultural
Arts Program Bylaws and agree to abide by them. I will insist that my children abide by the Bylaws as well. I
also understand that these bylaws may be amended by the executive committee as needed.
__________________________________________________________________________________________
HEALTH INSURANCE AND ASSOCIATED INFORMATION
Name of Insurance Company ____________________________________________
Policy #______________________________
Phone ____________________
Emergency Contact ____________________________________________________
Home: ______________________
Cell: ______________________
Health Problems and Medications Taken:
__________________________________________________________________________________________
Parent Signature: __________________________________ Date: __________________