Matilda Summer Camp Registration
Student Information
Name
*
First Name
Last Name
Student Gender
*
Please Select
Male
Female
Prefer Not To Answer
Other
School District
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
*
-
Month
-
Day
Year
Date
Age
*
Parent/Guardian Contact
Name
*
First Name
Last Name
Relationship to Student
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact
Name
*
First Name
Last Name
Relationship To Student
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please list any previous dance or acting experience:
*
How did you hear about us?
*
I give permission for my child’s photo to be taken and used for publicity on social media or other promotional platforms.
*
Please Select
Yes
No
I understand that all sales are final and there are no refunds
*
I agree
My Products
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Camper Registration
$
350.00
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
Submit
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