Summer Dance Camp with Instructor Autumn Gold

Summer Dance Camp with Instructor Autumn Gold

Youth Dance & Dramatic Movement | For Ages 10-17
Camper's Information
First Name*
Middle Name*
Last Name*
Birth Date*

MonthDayYear
Gender*

MaleFemaleOther
Address*
City*
State*
Zip*
Please select which Option(s) your child would like to attend

Option 1: JUNE: Every Mon & Thurs - $200Option 2: JULY: Every Mon & Thurs - $200Option 3: BOTH June & July - $400
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Parent /Legal Guardian 2*
Relation 2*
Cell Phone 2*

Area CodePhone Number
Work Phone 2

Area CodePhone Number
Emergency Contact Info
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2*

Area CodePhone Number
Email Confirmation
Parents Email (Please be certain to enter your email address)
Camper's Email
Other Information
How did you hear about this Dance Camp?
Health Information
Are immunications up to date?

YesNo
Any activity the camper should be restricted from?
List any allergies (ex: bees,peanuts, dairy)
Any dietary needs that we should know about?
Dance Camper Photo Release
I agree that photos of my child can be taken on used on for camp social media purposes

YesNo
Payment Information

$180.00 for camp + $20 for dance costumes = $200 per month
Method of payment

Paypal (QR Code Below)Venmo (QR Code Below)ZelleCheckCash App
- Be certain to enter your email address correctly on the registration form to receive confirmation via email.
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. The camp carries secondary insurance. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites.
Electronic signature, please initials*
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Summer Dance Camp with Instructor Autumn Gold

Camper's Information

Parent or Legal Guardian Information

Emergency Contact Info

Email Confirmation

Other Information

Health Information

Dance Camper Photo Release

Payment Information