Welcome to Centenary Dance Academy! We pride ourselves on providing a high standard of training in an inclusive and caring environment where everyone experiences the joy of dance. Whether you are an adult learning for the first time or working towards a professional path, we enable everyone to discover the joy, passion and excitement that comes from participating in the world of dance. Everyone is made welcome and parents are always able to watch!

Director: Inara Svalbe OBE, ARAD, Solo Seal, RTS, Dip ABS Artistic Director of Tap and Jazz: Lucy Flook CSTD Jazz, Bachelor of Education (Secondary), Bachelor of Arts (Dance and Drama), CSTD Jazz Award, Student Teachers Tap, Jazz, Theatrical, currently completing Masters of Education Artistic Director of Ballet: Glynnis Gordon-Eames Royal Academy of Dance Registered Ballet Teacher RADRTS, Royal Academy of Dance Certificate in Ballet Teaching Studies Tutor CBTS, Royal Academy of Dance Diploma in Dance Teaching Studies DDTS Practical Teaching Supervisor, SADTA Contemporary and Jazz (Associate), Dancecor

Information Pack Contents • • • • • • • • • •

Studio Locations Annual Events Classes on Offer Class Descriptions Fee Schedule Fee & Studio Policies Dance Attire Policy Uniform Order Form Enrolment Form Code of Conduct

Contact Us PO Box 476 Sherwood Qld 4075 07 3378 3436 [email protected] www.centenarydance.com.au www.facebook.com/centenarydanceacademy

Studio Locations Oxley Main Studio: 53 Seventeen Mile Rocks Road, formerly the Oxley Secondary College, now Qld Government Biosecurity Control Centre. It is in the performing arts hall (first building on the left). Access is via the service road at the roundabout opposite Kingsgate Street Oxley St John’s: California Road, Oxley in the St John’s Anglican Church hall. Centenary Studio: 37 Riverhills Road, Middle Park in the Uniting Church hall. Annual Events Concert: An end of year performance is held at the Schonell Theatre, St Lucia for all students. Holiday Workshops: During select school holidays, specialised dance workshops will be offered. Mid Year Studio Open Day: Students show off what they have learnt in class for family and friends. www.centenarydance.com.au

Centenary Dance Academy 2014 Classes

Enrol

Class

Length

Approx. Guide to Age

Creative Dance

45 mins

2009 – 2011 (must be aged 3)

Pre Primary Primary/Grade 1 Foundation RAD Grade 1 RAD Grade 2 RAD Grade 3 RAD Grade 4 RAD Grade 5 RAD Intermediate Foundation RAD Intermediate RAD Advanced Foundation RAD Advanced 1 Junior Professional Extension Adult Beginner Ballet Performance Troupe

45 mins 45 mins 45 mins 1 hr 1 hr 1 hr 1 hr 1 hr + 1hr 15 mins 1 hr + 1hr 15 mins 1 hr + 1hr 15 mins 1 hr + 1hr 15 mins 45 mins 1hr 15 mins 45 mins

2008 2007 2005 & 2006

CSTD Primary CSTD Grade 1 CSTD Grade 2 CSTD Grade 3 CSTD Grade 4 CSTD Grade 5 CSTD Grade 6 CSTD Grade 7 CSTD Grade 8 Intermediate Open Advanced Open Intermediate Open Technique Differently Abled Dance Performance Troupe Adult Beginner Jazz

45 mins 1 hr 1 hr 1 hr 1 hr. 1.5 hrs 1.5 hrs 1.5 hrs 1.5 hrs 1 hr 1 hr 1 hr 1 hr 1 hr 45 mins

After Grade 7 Exam After Grade 5 class - non graded class 16 years to adult Grades 3 to 5 Teens & Adults Upon Invitation Adults

CSTD Preliminary CSTD Elementary Bronze CSTD Elementary Silver CSTD Elementary Gold

45 mins 45 mins 1 hr 1 hr

2009 2006 2005 Contact CDA

Dance Foundations

Ballet

Contact CDA

Adults Upon invitation

Jazz 2007 & 2008 2006 2005 2004 At least 2003 and older At least 2002 and older Contact CDA

CSTD Tap

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CSTD Intermediate Silver/Gold CSTD Intermediate Gold Bar CSTD Advanced Gold Adult Beginner Adult Intermediate

1 hr 1 hr 30 mins 45 mins 1 hr

Contemporary Intermediate Contemporary Advanced Pas de Deux Junior Extension Ballet Intermediate Open Ballet Advanced Open Ballet Private Classes & Musical Theatre

1hr 1 hr 1 hr 45 mins 1 hr 1 hr 15 mins TBA

Contact CDA Adults 16 years to adult

Other 10 years plus Contact CDA Upon invitation Contact CDA

Centenary Dance Academy Class Descriptions Creative Dance Creative Dance is the perfect introduction to dance for a child aged 3 or 4 years. In this fun-filled class students explore dance, musicality, drama and imaginative play in a supportive and friendly environment. Our young dancers use scarves, musical instruments, costumes and more as they experience the joy of dance. Creative Dance is also a wonderful way for a child to develop a foundational understanding of skills such as listening to directions and interacting with peers. Pre Primary Ballet This class is based on the Royal Academy of Dance Pre Primary in Dance syllabus and introduces a wide range of basic dance, drama and musicality elements in a positive and supportive environment. The syllabus promotes and encourages enjoyment of movement. This class includes a free dance segment, encouraging students to independently draw on their developing dance skills and creativity. Primary/Grade One Foundation Ballet This class is based on the Royal Academy of Dance Primary in Dance syllabus and develops the students’ physical skills, stamina, creativity, expression and musicality using a range of sounds and musical styles. The syllabus promotes and encourages enjoyment of movement. This strong foundation prepares students for a successful transition to ballet and other dance genres at higher levels. Primary Jazz This fast-moving and fun-filled class caters for 5 to 7 year old boys and girls who love to dance and move. The class uses popular kids music to introduce basic elements of dance and musicality. In these lessons the students also learn valuable skills such as listening to and following directions and the social skills required when interacting with their peers. This helps ready a student for more formal learning situations both in dance and at school. RAD Ballet The studio offers RAD Ballet from Primary and Grade 1 through to the Vocational Grades. The Royal Academy of Dance (RAD) is one of the largest and most influential dance education and training organisations in the world. Continued Over

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The RAD Graded Examinations in Dance (Grade 1 – 5) consist of three disciplines: • • •

Ballet: the foundation and the most important part of the syllabus; Free Movement: incorporating styles such as Natural Movement, Contemporary and Classical Greek Dance; Character: the presentation of national styles, using original ethnic dance and music. The three styles — Hungarian, Russian and Polish — were selected due to their importance in the development of classical ballet.

The Vocational Graded Examinations (Intermediate Foundation to Advanced 2) provides an in-depth study of ballet developing technique, music and performance skills and introducing pointe work for female candidates. This highly-focused and practical training prepares students for a dance career. These levels are for students from 12 years old. Graded and Vocational Graded examinations are optional, upon recommendation by the teacher. All exam students are required to attend two syllabus classes per week to be considered for examinations. CSTD Tap We offer classes in the CSTD syllabi for students from five years of age. Fun, rhythmic, interesting and challenging, this style of dance is enjoyable to learn and exciting to perform. Annual examinations are optional upon recommendation by the teacher. Classes are available for teen and adult beginner, intermediate and advanced students. CSTD Jazz Our fun and energetic jazz classes are for male and female students from five years of age through to teens and adults. Students study a range of styles including hip-hop, modern jazz and contemporary dance. The classes include a foundational focus on strong technique as well as stylistic elements. Annual CSTD examinations are optional upon recommendation by the teacher. Students also have the opportunity to perform at a range of community events throughout the year. Intermediate and Advanced Open Jazz These classes are for students who have reached Jazz 5 level and would like to continue studying jazz and contemporary style without sitting CSTD exams. Consisting of technique and learning different styles, this class will keep your technique strong while focussing on learning routines and different combinations. Musical Theatre (song) Coming Soon7777.. Musical Theatre will consist of a group singing lesson led by a qualified and performance focussed tutor. Combining singing and dancing, this class will focus on vocal technique and performance confidence and is for students aged 12 and over. Differently Abled Dance We believe that dance is truly for everyone and this class ensures that everyone has the opportunity to access dance. Students in this class learn jazz, hip-hop and a little ballet to a range of music styles in this fun, friendly and supportive class. We cater for different levels of fitness and physical and other abilities. Students perform in the annual concert with great success! Contemporary Students in this class learn innovative choreography whilst drawing upon their creative strengths. This is an athletic class that enables students to study cutting-edge dance techniques. Specialist teachers are employed to teach these classes.

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Professional Open Ballet: Junior Extension, Intermediate & Advanced For students who aspire to a professional career or for those who wish to study ballet more seriously, we offer open ballet classes at intermediate and advanced levels. The classes do not draw upon a set syllabus but instead follow the format of a professional class, encouraging students to develop their ability to engage with ballet terminology and master various combinations. The intermediate and advanced classes are taught by Tracey Carrodus (former principal dancer at Sydney Dance Company). Adult Beginner Classes: Ballet, Jazz and Tap Have you always wished you were able to dance but never had the opportunity? Or did you stop dancing at some point but now want to return? Our popular beginner classes are perfect for adults who have no prior dance experience or for those who are ‘out of practice’. Our classes are for people of all shapes, sizes and ages. You will receive the utmost support and encouragement from our friendly teachers who will cater for your individual levels of fitness and prior experience (if any). Participation in the annual performance is an amazing experience but always optional! Jazz Performance Troupe Students in our jazz performance troupe showcase a variety of routines at local festivals, fetes and other events. These dancers display outstanding technique, performance ability and commitment to dance. By invitation only. Ballet Performance Troupe Students who have developed secure ballet technique and have demonstrated a commitment to their dance will be invited to join this group. Students will learn a Performance Group Dance/s to showcase at fetes, open days and eisteddfods. Students must be committed and be available to attend all rehearsals and performances. By invitation only. Pas de Deux Pas de deux work is extremely beneficial for senior male and female students as the practice of holding sustained positions is essential for both strength and technique consolidation. Students must demonstrate secure posture, ballet technique and good core stability to be considered for this class. Pas de deux classes for girls are an extension of their pointe and ballet classes. By invitation only. Other Classes From time to time other classes may be offered according to interest. Examples of such classes include Repertoire and Ballroom. Please contact us if you are interested in a dance style that you do not see offered here. Private Lessons Private lessons can be arranged by appointment only with the Jazz/Tap Director and Ballet Director. One on one dance tuition is extremely beneficial before examinations and other specific dance events.

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2014 Centenary Dance Academy Fee Schedule Current as at 23 December 2013 Class

Term Price

RAD Ballet

Class

Term Price

Dance Foundations

Pre Primary

$105.00

Creative Dance

Primary / Grade 1 Foundation

$105.00

Grade 1

$105.00

Performance

Grade 2

$150.00

Ballet Performance Troupe

$126.00

Grade 3

$150.00

Jazz Performance Troupe

$180.00

Grade 4

$150.00

Contemporary

Grade 5

$150.00

Intermediate Contemporary

$150.00

Intermediate Foundation

$185.00

Advanced Contemporary

$150.00

Intermediate

$185.00

Other

Advanced Foundation

$185.00

Musical Theatre(Singing)

Advanced 1

$220.00

Private Classes

Junior Professional Extension Intermediate Professional Open

$150.00

CSTD Jazz

$160.00

Primary

$105.00

Advanced Professional Open

$150.00

Grade 1

$140.00

Pas de Deux

$160.00

Grade 2

$150.00

Adult Beginner

$175.00

Grade 3

$150.00

Grade 4

$150.00

Other Ballet

Tap

$105.00

$150.00 Per lesson. Price upon request.

CSTD Preliminary

$105.00

Grade 5

$190.00

CSTD Elementary Bronze

$150.00

Grade 6

$190.00

CSTD Elementary Silver

$150.00

Grade 7 & 8

$190.00

CSTD Elementary Gold

$150.00

Other Jazz

CSTD Intermediate Silver/Gold

$150.00

Intermediate Technique

$150.00

CSTD Intermediate Gold Bar

$150.00

Intermediate Open

$150.00

CSTD Advanced Gold

$75.00

Advanced Open

$150.00

Adult Intermediate

$150.00

Differently Abled

$140.00

Adult Beginner (non-CSTD)

$105.00

Adult Beginner

$105.00

• • • • • • • • • •

Annual Enrolment Fee: $22 per student or $33 per family (two or more students) 10% discount will apply to individual students enrolled in two to five classes 15% discount will apply to families enrolled in six or more classes Adult students can apply for casual billing but a minimum of five classes per term must be paid Concert participation fee: to be advised Lesson fees will be charged by the term and are payable by the second week of each term. Fees not received by the end of the fourth week with subject to a 10% administration fee There will be classes on ALL pupil free days but NOT on public holidays You will receive a credit for the public holiday if it falls on your lesson day Prices are inclusive of 10% GST

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•

Please see our Studio Policies for more detailed information about our fees

Centenary Dance Academy Studio Policies

Parent Viewing: At the discretion of the teacher, parents are permitted to view classes. However, we kindly request that you do so at a distance and without interrupting the class to enable the teacher to teach without distractions. We also request that your other children are actively supervised. Communication: Notices and invoices are distributed via email where possible. All other notices will be distributed at the end of class or posted. If you have a concern please approach the teacher at the conclusion of the lesson, phone Inara Svalbe OBE (Studio Director) on 3378 3436 or email [email protected]. Please read our emails carefully as they contain important information (e.g. concert information). We also publish information and updates on our website: http://www.centenarydance.com.au End of Year Concert: We stage a professional-style end of year concert at the Schonell Theatre. Students prepare a dance in class then attend one stage rehearsal, one theatre rehearsal and one/two performances. There is a costume charge which will cover either a costume for you to own or costume hire. You are generally expected to provide your own tights and clean dance shoes (some variations may occur). Any change from your costume is returned to you. A small performance/participation fee will be charged to cover theatre and administration costs (TBA). Costume Fee: Concert Participation fee: TBA. You will be advised of the cost as early as possible. Fees will be due early term three. Costume fees are separate to the concert participation fee and are paid in cash to the teacher of the class by the due date (early term three). Once the due date has passed, we are not able to provide a refund should you withdraw from the concert but you will still receive your costume. Fees: Annual Enrolment Fee: $22 per student or $33 per family (two students or more). Fees for lessons will be charged by the term and are payable by the second week of each term. Fees not received by the end of the fourth week are subject to a 10% administration fee. There will be classes on ALL pupil free days but NOT on public holidays. You will receive a credit for the public holiday if it falls on your lesson day. 10% discount will apply to individual students enrolled in two to five classes and 15% discount will apply to families enrolled in six or more classes Payments: Payments can be made by cash, cheque, direct deposit or credit card (see invoice for details). If handing to the teacher, please ensure it is in a sealed and named envelope and given to the teacher immediately before or after class to ensure no delay or interruptions are made to lessons. Unfortunately refunds can not be made for classes that are missed; however students may take a ‘make-up’ lesson with a comparable class. If a student withdraws their enrolment before the end of a term, the full term’s fees will remain payable. Refunds and credits will not be issued for students withdrawing mid-term. Your child will automatically be re-enrolled for the following term unless notification has been received prior to the start of term. A student must be officially withdrawn by informing the office (in writing or phone) as otherwise fees will continue to be invoiced as the student’s place is held in the class. If you are experiencing difficulty paying fees then please contact Centenary Dance Academy as soon as possible so that a mutually suitable payment plan can be implemented.

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Photography & Video Footage: For privacy reasons we ask that you gain the permission of other parents (dancers aged under 18) or dancers (aged 18 and over) when taking photos or video footage. Photos and video footage can only be taken during class time at the discretion of the teacher and on the condition that it does not distract the students or teacher. Students who participate in our open day and concert may be photographed or filmed by other spectators. By allowing your child to participate, you give permission for this to occur. Your child should not participate if you do not with this to occur. All students in the end of year concert will be professionally photographed as well as filmed for our DVD even if you have not granted media permission. If you do not wish this to occur then you will be unable to take part in the concert. We will not use these photos in our studio website etc without permission. Child & Youth Safety Policy: All of our teachers hold a Blue Card or an Application for a Blue Card in line with Queensland Government legislation. Please contact us for a full copy of our child and youth safety policy. All students, parents and teachers are to sign a Code of Conduct as part of our policy. Reminder: CDA is not responsible for students before or after their class. Parents are to collect their children as soon as possible after their class has concluded. Current as at 23 December 2014.

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Centenary Dance Academy Dance Attire Policy 2014 All Students: • Hair secured off the face & bring a water bottle • Intermediate Foundation Ballet & up: students to wear hair in a classical bun • If cold: white uniform dance jacket or crossover (no jumpers) • Exam Requirements: students must wear the CDA uniform as listed • Our policy ensures freedom of movement and enables the teacher to clearly see the body in order to promote sound technique and safety Students in the following levels must wear CDA uniforms to class: • Ballet: Grade 2 to Grade 5 • Jazz: Grade 2 to Grade 5 • Tap: Elementary Bronze to Intermediate Gold Bar Ballet Female: • Navy uniform leotard • Pink leather ballet shoes • Demi-pointe/pointe shoes: when advised by teacher • Grade 1 & 2: pink ballet socks, low heeled black character shoes, mid-calf character skirt with blue ribbons • Grades 3 to 5: pink ballet tights, high heeled (Cuban) black character shoes, mid-calf character skirt with blue ribbons • Students in the Higher Grades & Vocational Exams should see Ballet Director Jazz & Tap Female: • Black uniform leotard • Jazz: Camel jazz shoes • Tap: Camel tap shoes • Matte skin coloured tights (outside of exams, students may wear any of the other CA dance wear including shorts, camisole top, etc) Creative Dance to Primary Ballet: • Female: leotard and ballet skirt • Male: plain t-shirt and close fitting shorts • Dress up costume (including tutus) • Leather ballet shoes (not Jiffies) Adult Beginners: Any clothes that you can comfortably move in, similar to what you might wear to the gym, Pilates, etc. Talk to your teacher for advice regarding dance shoes.

Ballet Male: • White leotard • Navy male ballet tights • Leather ballet shoes and socks • Grade 1 to 5: white leather ballet shoe • Other students: black leather ballet shoe • Grade 1 to 5: black male character shoe • Male protector

Jazz & Tap Male: • CDA uniform singlet • CDA unisex dance pants • Black jazz or tap shoes

Primary & Grade 1 Jazz, Preliminary Tap • Female: leotard, optional dance shorts • Male: plain t-shirt/singlet & shorts • Female: camel jazz and camel tap shoe • Male: black jazz and black tap shoes Older Students: Students in levels higher than those listed above may wear dance attire of their choice if it is similar to uniform requirements (e.g. leotard of your choice).

See next page or teacher for uniform order form! For purchasing dance shoes: BLOCH Shop 23, The Emporium Traders 1000 Ann St, Fortitude Valley Ph. 3852 1855 www.bloch.com.au www.centenarydance.com.au

DANCE PACIFIC Unit 4,1326 Boundary Rd Wacol Ph. 3271 1935 www.dancepacific.com

SUE’S SHOP (The Dance Warehouse) 871 Old Cleveland Road, Carina Ph. 3398 5120 www.suesshop.com.au

Centenary Dance Academy Uniform Order Form Please place an order using the sizing chart. Lynette (Admin) Email: [email protected] Phone: 07 3278 3477 Payment Options: • Cash • Cheque to Centenary Dance Academy • Electronic Transfer to: o BSB: 084 255 o Account No: 16 827 9359 o Please note that this the same dance fees account ----------------------------------------------------------------------------------------------------CDA Uniform Order Form Dancer’s Name: ___________________________________________________________ Teacher/s: _______________________________________________________________ Quantity

Item

Cost

Navy leotard with logo Navy boyleg shorts with logo

$25 $15

Black leotard with logo Black “boyleg” style shorts with logo Black & white camisole top with logo Black & white shorts with logo Black & white 3/4 pants with logo Black & white unisex pants with logo White male tank top with logo Black & white striped leg warmers: Adult Convertible ballet tights: Child T S M L Convertible ballet tights: Adult S M L XL

$25 $15 $20 $20 $25 $30 $25 $10 $10 $15

TOTAL

□ Cash/Cheque Total Payment Enclosed □ Total Amount Paid via Electronic Transfer

Current as at 23rd December 2014

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Size

Sizing / Measurement Chart from our Supplier

Please Order Larger Size. Keep Tag On For Exchange. When trying on, please wear underwear.

Children’s Dance Wear Size Chart – Metric Toddler

Small

I

M

L

Age (yr s)

2-4

5-6

7-8

9 - 10

11 - 12

Height (cm)

99 - 104

109 - 117

122 - 127

135 - 140

145 - 152

Chest (cm)

51 - 53

56 - 58

58 - 64

64 - 69

71 - 74

Waist (cm)

48 - 51

51 - 53

53 - 56

56 - 58

61 - 64

Hip (cm)

53 - 56

56 - 61

61 - 66

66 - 74

74 - 79

Girth (cm)

42-44

45-47

48-50

51-53

54-56

Ladies’ Dance Wear Size Chart - Metric Small

Medium

Large

Extra Large

XXL

Height (cm)

147 - 160

157 - 168

168 - 173

173 - 178

178 - 183

Weight KG

43 - 48

48 - 52

52 - 57

57 - 61

61 - 66

Bust (cm)

76 - 84

84 - 89

89 - 94

94 - 99

99 - 104

Waist (cm)

56 - 61

61 - 66

66 - 71

71 - 76

76 - 81

Hip (cm)

79 - 84

84 - 89

89 - 94

94 - 99

99 - 104

Girth (cm)

57-59

60-62

63-65

66-68

69-71

USA equivalent 4

6

8

10

12

UK equivalent

10

12

14

16

8

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2014 Centenary Dance Academy Enrolment Form PERSONAL DETAILS Student Surname: ____________________ First Name: _______________________: Date of Birth: __________________ Age at 31/12/14: _________ Sex: M

F

Guardian’s Name: ___________________________________ Ph# ________________________ Guardian’s Name: ___________________________________ Ph# ________________________ What is the best number for us to contact you on? (Mobile preferred): _______________________ Home Phone: _______________________

Other Phone: ______________________________

Address:________________________________________________________________________ #1 Emergency Contact Person:_______________________________ Ph# ___________________ Relation to Student: ______________________________________________________________ #2 Emergency Contact Person:______________________________ Ph# ___________________ Relation to Student: ______________________________________________________________ EMAIL COMMUNICATION Please leave blank if you do not want to receive communication/invoices via email. _________________________________________________________________________ MEDICAL INFORMATION Allergies: _________________________________________________________________________ Treatment: ________________________________________________________________________ Anything else that you think we should know: ______________________________________________ __________________________________________________________________________________ I have read and understand the Studio & Dance Attire Policies (including the section on fees) and agree to abide by these. I understand that if I do not abide by these policies then enrolment at CDA may be jeopardised. Name: _________________________Signature: ________________________ Date__________ MEDIA RELEASE Please sign ONLY if you give permission. I give permission for photographs and video footage to be taken of myself / my child and used in the local media, advertising, on the CDA website/facebook page or for other studio purposes. Name: ____________________________Signature: ________________________ Date: __________ PLEASE TURN OVER TO CONTINUE ENROLMENT ------------------------------------------------------------------------------------------------------------------------------------Office Use Only □ Rolls □ Email List □ Entered □ Invoiced www.centenarydance.com.au

HOW DID YOU FIND OUT ABOUT US? (Please tick) □ I am an existing student or family □ Google □ I am a returning student or family □ Our CDA Website □ Other (please list) □ Word of mouth (please list

Code of conduct for children and young people under 18 As children and young people who are part of Centenary Dance Academy we agree that: • We will respect other children, young people and adults; • We will cooperate and play by the rules; • We will listen and receive instructions; • We will control our temper; • We will have a say about what we are involved in; • We will speak up if we are worried or concerned about something; • We will not be a bully or accept any bullying that we see. Code of conduct for parents/carers and adult students As a parent/carer of a child involved in the service provided by Centenary Dance Academy, or as an adult student, I agree that: • I will respect the rights, dignity and worth of every person, regardless of their abilities, gender, religion or cultural background; • I will respect the decisions of employees/officials and teach children to do likewise; • I will focus on and encourage children’s efforts and performance; • I will support all efforts to remove any form of abuse in this organisation and encourage a safe and supportive service environment; • I will raise any issues or concerns with staff; • I will not treat any child or young person in an unfair, unjust, or discriminatory manner; • I will not smoke on the organisation’s premises; • I will not drink alcohol or use illicit substances while on the organisation’s premises except within the parameters of an adult-only function e.g. wine and cheese night. In the event that the code of conduct for interacting with children and young people is breached, actions will be taken in accordance with our organisation’s plan for managing breaches of the child and youth risk management strategy. This may include exclusion from class. I have read, understood, and will act in accordance with the above code of conduct. Name/s: __________________________________________________________ Date:___________ Signature/s: _______________________________________________________________________

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