THON 2013 Dancer Registration Packet

DANCER REGISTRATION PACKET
2013 Penn State IFC/Panhellenic Dance Marathon
Dancer Registration Form
Dancer A
Name: __________________________________ PSU ID #:________________
(Last) (First) (MI)
Local Phone: ___________________________ Sex: Male Female
Local Address: ___________________________
___________________________
Email: ___________________________
Partners Name: ___________________________
List a local person that we can contact in case of an emergency
(Someone in the State College area with access to a car):
Name: _________________________ Phone: __________________
Address: _________________________
_________________________
Relation: _________________________
Email: _________________________
Parent Information for emergency contact
Name: __________________________ Phone: _________________
Address: __________________________
__________________________
Email: __________________________
COUPLE # ___________
In consideration for the opportunity to participate in this event, which is co-sponsored by the Interfraternity and
Panhellenic Councils and takes place on the premises of The Pennsylvania State University, I hereby release all
parties and their employees and representatives from any and all liability for injuries or damages that I may sustain
as a result of my participation in the Penn State IFC/Panhellenic Dance Marathon 2013. I also realize that any
medical expenses incurred, as a result of my participation in this event, will be my sole responsibility. By my
signature below, I hereby acknowledge that I am at least 18 years of age.
Dancer A: ___________________________________ (Signature)
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