WDS Summer Dance Camp Registration

Summer Dance Camp Registration

at Wilson's Dance Studio
Session 1: June 24 - June 28Session 2: July 15 - July 19
Parent/Guardian Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Child's Name*

First NameLast Name
Child's DOB*

MonthDayYear
Child's age - date of camp*
Enter current age
Is your child potty trained and knows how to properly clean themselves without help?*
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
NoMondayTuesdayWednesdayThursdayFriday
NoMondayTuesdayWednesdayThursdayFriday
Primary Doctor*
Physician or Hospital
Phone Number*
Area Code + Phone Number
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Informed Consent and Acknowledgement

As Parent and/or Guardian, I acknowledge that I have voluntarily signed up my child(ren) to participate in the Summer Dance Camp at Wilson's Dance Studio. I hereby give my approval and consent for my child’s participation in any and all activities prepared by Wilson's Dance Studio during the selected camp session. In exchange for the acceptance of this camp, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve all risks from Wilson's Dance Studio and all its respective owners, instructors, directors, employees, volunteers, and any representatives from any and all liability for injuries or death to the above-named child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury or death to the above-named child, I hereby waive all claims and any liability against Wilson's Dance Studio including all coaches, affiliates, participants, sponsors, families, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all Summer Dance Camp activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

I also agree that I, my assignees, heirs, distributees, guardians, next of kin, spouse or legal representatives will NOT make a claim against, sue or attach the property of any Releasee in connection with any of the matters covered by the foregoing release.
Parent Signature*

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Waivers

As Parent and/or Guardian, by signing this form, I acknowledge and give consent to Wilson's Dance Studio to photograph or video the above-named participant, while participating or involvement in the Summer Dance Camp. I understand that these images may be used for brochures, advertisement or other forms of media and that I / we will NOT receive any compenstation for such use. I agree that these images may be used for intended publication, promotion, and marketing by Wilson's Dance Studio. All negatives, prints and electronci files record or designed by Wilson's Dance Studio will be the sole property and rights of Wilson's Dance Studio and no other images shall be permitted without the express written consent of Wilson's Dance Studio.
Parent Signature*

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Behavior

As Parent and/or Guardian, I understand that my above-named child is expected to be on their best behavior while attending the Summer Dance Camp. I will talk with my above-named child about manners, kindness and respect towards other campers and leaders, using appropriate words, being respectful to other peoples property, keeping hands to themselves and the importance of cleaning up after themselves. I will send my above-named child dressed appropriately and comfortable for the daily activities.

I understand that Wilson's Dance Studio will do its best to provide a safe, fun and healthy environment for all attendees. Wilson's Dance Studio will also do its best to keep situations controlled and provide protection to all attenees. If an incident arises or if my above-named child participants in a situation, Wilson's Dance Studio will notify me as soon as possible. If my above-named child receives too many warnings or is not respectful of the Summer Dance Camp rules, they may be removed from the Summer Dance Camp program WITHOUT a refund to any paid costs.
Parent Signature*

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Medical Release and Authorization

As Parent and/or Guardian, I understand that Wilson's Dance Studio does NOT provide accidental injury insurance for participants in this Summer Dance Camp. I do consent to allow PROFESSIONAL medical treatment / care to the above-named child in case of an emergency and understand that I am responsible for ALL fee incurred for such treatments.

I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician or licensed medical emergency team to proceed with any medical or minor treatment, x-ray examination for the named participant. In the event of an emergency arising out of serious illness, the need for major surgery, significant accidental injury or death, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances for the above-named child.
Parent Signature*

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Payment & Fees

As Parent and/or Guardian, I understand that full payment and fees must be made within the next or two after registration is approved by Wilson's Dance Studio. I understand that payment and fees are non-transferrable and non-refundable. If an emergency arises to where the above-named child cannot attend the full week, proof must be given and Wilson's Dance Studio will keep a $100 non-refundable deposit to cover fees for enrollment.

$300 Summer Dance Camp Session payment can be made via Zelle (925-207-6097: Hannah Wilson) or Venmo (@wilsonsdancestudio).
Parent Signature*

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Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent Signature*

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