Summer Holiday Program Enrollment Form
Student Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
School Grade
Age
Gender
Female
Male
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian & Emergency Contact Information
Parent/Guardian Contact Name
First Name
Last Name
Relationship to Child
Mother
Father
Uncle
Aunt
Grand Parent
Family Friend
Other
Email
example@example.com
Phone Number
Please enter a valid phone number.
DL#
Is the address same with the child?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Date & Times
Please select date(s) & time(s)
FULL PROGRAM
Monday 20th Jan 2025
Tuesday 21st Jan 2025
Wednesday 22nd 2025
Thursday 23rd 2025
Friday 24th Jan 2025
Participant Health Information
Doctor
First Name
Last Name
Phone Number
Please enter a valid phone number.
Does the child have any medical conditions?
Yes
No
Please give details
Does the child have any allergies to food, medications, or insect bites?
Yes
No
Please give details
Medical Insurance Information
Insurance Company
Phone Number
Policy
Policy #
Group #
Policy Holder Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agreement & Consent
I, parent/guardian of the participant, agree with the following statements:
I understand that I am responsible for paying when my child is enrolled in the Holiday Program. Payment is due at time of registration.
I give permission that my child may be photographed, videotaped, and/or interviewed for the purpose of the Camp's promotional use.
I give consent for my child to be transported by the Camp for field trips or emergency care this includes trips to the local park or other outdoor activities.
I have received and read a copy of the Camp Handbook. I have also received and read the Parent and Student Code of Conduct.
Each child needs to bring their own lunch/snacks provided it does not need heating or cooling, and is clearly labeled with the child’sname and is healthy, Fast food and junk food is not permitted.
I understand that Midland Dance Studios will not assume responsibility for any injury incurred while participating in dance, athletic activities, holiday programs physical activities, parent/child event and outings, special events, sports programs, or any related activity on the holiday program. The parents understand and accept certain risks of injury are inherent during participation in these programs and events. Nor will Midland Dance Studios be responsible for any lost or stolen items while students and/or program participants are using the studio facilities, on the studio premises, or on off-site program locations. I, the undersigned for myself and my children, I do hereby release the camp and its employees and agents from any and all claims for injury, loss, or damage I may suffer as a result of my childs participation. This includes any injury caused by negligence, if any, of the MDS officers, employees, agents, volunteers,or the negligence of anyone else associated with the programs.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
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