Registration
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2018 Summer Camp Full Day Registration
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Relationship to Student
*
Both Parents
Father
Grandparent
Guardian
Mother
Other
Parent
Student
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Please provide the name and phone number of an Emergency Contact if we are unable to reach you
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Questions/Options:
Select YES if you would you like to register for BOTH WEEKS OF CAMP, and SAVE 10% off the 2nd week's fee. You do not have to register for the 2nd week yourself; we will do this for you.
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Yes
No
Please supply an emergency contact name and number for us to reach you during Summer Camp.
*
Summer Camp Registration includes a FREE Summer Camp 2018 T-Shirt for tie-dye if you register by June 1. Please enter the Student's T-Shirt Size (Youth XS/ S/M/L/XL, Adult S/M/L/XL)
*
Please list any Allergies or Medical Conditions that your child has .
*
Registration requires a deposit of $100/child (balance due by June 15). Supply credit card details below. Select YES to charge your card the full balance, select NO to charge deposit only.
*
Yes
No
If you have a COUPON CODE, please enter it here.
Additional Information:
Liability Release
(Show-Hide Details)
I have enrolled the above mentioned child in a program of strenuous physical activity offered by the Academy of Dance. In consideration of myself, and the above named person's participation in this program, I for myself, my heirs and assigns hereby release the Academy of Dance, the owner/director, Amanda Braley, her family and employees from any liability now or in the future from any injury, however caused, occurring before, during or after participation in the above stated program offered at the Academy of Dance, or at any time while in the vicinity of the premises of the above stated business or in any activity sponsored, represented or organized by the Academy of Dance.
I've read the above and agree.
Talent Release
(Show-Hide Details)
I permit photographs or videos containing the above mentioned child's image to be used in future online or print marketing by the Academy of Dance or any legal entity belonging to Amanda Braley.
I've read the above and agree.
Sunscreen & Water Policy
(Show-Hide Details)
Our Summer Camps are held outdoors in the middle of summer, and we take sun protection and hydration very seriously. You agree to supply your child with a water bottle and enough sunscreen to last them throughout camp. You are responsible for applying sunscreen to your child before you check in to camp each day, and for making sure your child knows how to apply their own sunscreen and how much to apply (we can assist when requested). We will ensure that every child has access to water to refill their water bottle and that full day campers reapply sunscreen during the day (weather permitting). We will obviously take a common sense approach if we believe children are being overexposed to the sun or appear dehydrated. Click to agree to this policy.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Amex
Discover
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
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Exp Year:
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2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
Address Line 1:
Address Line 2:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
*
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