EmailMe Form - REVyouth Arts Summer Camp Registration

Dancer Information

Student Name *

First Last

(Please use a separate form for each student.)

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Student's Email

Student's Cell Phone

### - ### - ####

Student's Home Phone

### - ### - ####

Age *

Student's Date of Birth *

MM / DD / YYYY

Primary Language

English

Spanish

ASL

Other

(i.e assisted device)

Physician's Name *

Physician's Phone *

### - ### - ####

Does the student have any medical conditions or concerns of which we should be aware? *

Is there any additional information you would like to provide? *

Emergency Information

Emergency Contact Name *

First Last

Relationship to Students *

Phone *

### - ### - ####

Parent/Guardian Contact

Name *

First Last

Relationship to Student *

Email *

Cell Phone *

### - ### - ####

Work Phone

### - ### - ####

Please read and sign below.

By your signature below, you acknowledge that photographs and/or video may be taken of the student, and that REVolutions Dance Inc. may use such media and/or likenesses in print, on the Internet, and/or for training purposes. If you have an objection to the use of your student’s image, please contact REVolutions Dance Inc. before completing this form.

Signature *

Clear

Date Time *

MM / DD / YYYY