Youth(s) Only

Membership Application for Youth(s) Only

We hereby request becoming members of the Rockin’ Squares!
Please create club badges using our first names below.

Please accept my check for dues made payable to Rockin’ Squares. (QR code available on request.) Check #: *

* Indicates required field

Responsible Adult Name *

First

Last

Youth 1 Name *

First

Last

Birthday of 1st Youth *

Youth 2 Name *

First

Last

Birthday of 2nd Youth *

Youth 3 Name *

First

Last

Birthday of 3rd Youth *

Additional Youths- Names and Birthdays *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alt. Phone Number *

Email 1 *

Email 2 *

We hereby give permission for our phone numbers, birthdates (not year), and e-mail addresses to be shared with members of the club. *

YES NO

I also understand photos and videos may be taken during classes and at dances which may be used in the future for marketing purposes and give our permission for these photos and video to be shared within the square dance community. *

YES NO

Responsible Adult's Signature *

(By typing name here acknowledges electronic signature)

Date Signed: *

EMERGENCY CONTACT INFO

Emergency Contact Name *

First

Last

Relationship *

Emergency Contact Phone *

Emergency Contact Email *

Submit Application

Please fill out a Youth Permissions form for each youth