EmailMe Form - The Dance Academy Summer Camp 2017 Registration

Student's Name *
First Last
Date of Birth *
Sex
Male
Female
School Attending
Grade in the Fall *
Parent or Guardian Name *
First Last
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Email *
Home Phone *
### - ### - ####
Alternative Phone
### - ### - ####
Emergency Contact Name (Other than Parent listed above) *
First Last
Relationship
Emergency Contact Phone *
### - ### - ####
Additional Contact
Phone
### - ### - ####
Please Note:
By signing this agreement, I agree to hold harmless The Dance Academy and The Children’s School for any damages or liabilities arising out of or in connection with my student’s enrollment at The Dance Academy Summer Camp. I give permission for the student named above to take part in all Dance Academy activities. In the event of illness or accident to the student and the above people cannot be reached, school personnel is authorized to provide first aid, transport the student to any hospital and to authorize emergency medical or dental care by a duly licensed physician or dentist, and hospital care.
Signature of Parent or Guardian *
Clear
Allergies, injuries, operations, restrictions on physical activity, or anything else we should know about your child: *
Summer Ballet Intensive Level I
9:00 a.m. - 3:00 p.m.
June 19 - 30 - for Ages 9 and Up ($700)
Summer Ballet Intensive Level II
9:00 a.m. - 3:00 p.m.
June 19 - 30 for Ages 12 and Up ($700)
Summer Fun Dance
9:00 a.m. - 12:00 p.m.
July 3 - 14 for K-4th ($350)
July 3 - 7 (no camp July 4th) for K-4th ($165)
July 10 - 14 for K-4th ($195)
Dancing Princesses
9:00 a.m. - 12:00 p.m.
July 17 - 21 for PreKindergarten-3rd ($195)
Mickey Mouse Club
9:00 a.m. - 12:00 p.m.
July 24 - 28 for K-4th ($195)