Sign Up - Cypress Creek Church

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Which class(es) are you registering for?*

4 Year Olds - Kinder

1st Grade - 2nd Grade

3rd Grade & Up

Child Information:

How many children are you registering?*

Please enter a number greater than or equal to 1.

Child(ren):*

First Name

Last Name

Date of Birth

Medical Information/Allergies:

Parent Information:

Parent Name*

First Last

Phone*

Email*

Add me to the following Email Lists, if I'm not already!

Monthly Kids Newsletter

Cypress Weekly

Emergency Contact*

Name:

Phone Number:

Insurance*

Insurance Company:

Policy #:

Payment

Dance Alive Registration

Payment Preference*

Pay in Full

Pay Installment

Request Scholarship

Total

Credit Card*

Card Details

Cardholder Name

Billing Address*

Street Address Address Line 2 City State ZIP Code

I, the undersigned, hereby release Cypress Creek Church, it's agents, employees, officers and servants, from any and all damages and injuries which may occur while (I/ my child) is participating in any/all Cypress Creek Church activities, on or off the premises. I also give my permission for Cypress Creek Church leadership to seek medical attention by a licensed physician in the event of a medical emergency. I certify that I have the legal authority to execute this release on behalf of (myself/ my child). I also agree, by signing below, that the above information is true and correct to the best of my knowledge.

Participant or Parent/Guardian Signature (if under 18 yrs. old)**

Date*