Summer Intensive 2024 Registration Form

SUMMER INTENSIVE 2024

August 26-30 9:00 am to 12:00 pm
Students Name *

First NameLast Name
Birthdate D/M/Y
Students Name

First NameLast Name
Birthdate D/M/Y
Students name

First NameLast Name
Birthdate D/M/Y
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number*
Home Phone Number (if different than mobile)
Please enter a valid phone number.
E-mail*
example@example.com
Health concerns
I authorize Leisa Whalen to use photographs taken of my child while attending Leisa's School of Dance. Photographs may be used to promote programs or be used in or as part of publications, newsletters, advertisements, website and displays intended for the general public.

yesno
I, the undersigned acknowledge that the participation in dance education involves strenuous physical activity and that Leisa's School of Dance, Leisa Whalen, instructors and guest choreographers will not be held responsible for injury of any kind as a result of participation. By signing this agreement, I acknowledge the contagious nature of Covid-19 and agree to assume the risk that my child(ren) and I may be exposed or infected by Covid-19 by attending activities at Leisa's School of Dance.
Signature

Clear
Should be Empty:

SUMMER INTENSIVE 2024