Once Upon a Summer Dance Event 2019 Wells
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Relationship to Student*
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * 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
Please supply an emergency contact name and number for us to reach you during Summer Camp.*
Please list any Allergies or Medical Conditions that your child has .*
If you have a COUPON CODE, please enter it here.
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:  
Name as it appears on card:
Card Expiration Month:   Exp Year:
Address Line 1: Address Line 2:
City: State: Zip: