Unified Dance -Worcester Spring 2023

Unified Dance Program- Worcester Spring 2023

Charlotte Klein Dance Centers will be hosting a Unified Hip Hop class for people age 16+ at 1122 Pleasant St in Worcester on Fridays from 6:15-7:15. The program will run for six weeks -April 14, 21, 28, May 5, 12, 19 , and will be coached by our very own office staff Ali Phaneuf!

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone #*
Email*
Parent/Guardian Name
First Last
Parent/Guardian Phone #
I am a(n)*
- Athlete (Dance with intellectual disabilities or ASD)
- Unified Partner (Dancer without intellectual disabilities or ASD)
Does Athlete have current SOMA Medical on file?*
- Yes
- No
Athlete Medical
If Athlete does not have valid medical on file, please complete one and submit to SOMA before the event. All athletes are required to complete this form in order to play. Forms can be downloaded at the link below. A doctor/PCP exam is required (forms are valid for three years from exam date - so it can be an old exam date used). Completed forms can be emailed to Ops@SpecialOlympicsMA.org
Medical Form
Download medical form
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Unified Dance Program- Worcester Spring 2023

Athlete Medical

Medical Form