Clone of Petites Power-Up

Clone of Petites Power-Up

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To reserve your spot, you must complete the form below accurately.
RATES:

$50 registration fee/ $25 for any dancer enrolled in another Dancers Don't Take Breaks Summer Program-(NONREFUNDABLE)

Tuition: $150
Birth Date*

MonthDayYear
Dancer's Name*

First NameLast Name
Home Phone Number*
Format: (000) 000-0000.
Mobile Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Preferred Name*
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My child is a student at Wissahickon Charter School, Thomas Mifflin Elementary School, Universal Creighton or Girls High

YesNo
If yes, please upload a copy of their most recent report card as proof of enrollment.

Cancelof
Please provide any medical or dietary restrictions you have*
How did you hear about our bootcamp?*

Family Information
Parent 1/Guardian's Name*

First NameLast Name
Parent 2/Guardian's Name*

First NameLast Name
Contact Phone Number*
Format: (000) 000-0000.
Alternative Phone Number*
Format: (000) 000-0000.
E-mail Address*
example@example.com
Alternative E-mail Address*
example@example.com

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Format: (000) 000-0000.
Relationship to Student*

Additonal Questions
Is this dancer a sibling?*

YesNo
If yes, please list the sibling's name and birthdate*
What level would you consider your dancer? Please be open to understanding that dancers will be assessed by our professional staff. There will be instances where parent's and staff's assessments will differ.*

NoviceIntermediateAdvanced
Please briefly list your child's dance experience (studio(s) they have attended, number of years child has danced, awards received etc)*
Does your child have any social-emotional or developmental needs that we should be aware of? If yes, please elaborate. *
If your child has any allergies, please list them below.*
Is your dancer interested in staying with us in the fall?

YesNo

Liability Waiver
The X-Perience Dance Company Camp Participation Waiver

I, the undersigned participant (or parent/guardian if the participant is under 18), acknowledge and agree to the following terms as a condition of participation in The X-Perience Dance Company camp:

Assumption of Risk – I understand that dance and physical activities involve inherent risks, including but not limited to falls, injuries, and physical exertion. I voluntarily assume all risks associated with participation.

Release of Liability – I hereby release, waive, and hold harmless The X-Perience Dance Company, its directors, instructors, staff, volunteers, and affiliates from any and all liability, claims, or demands arising from participation in the camp, including personal injury, property damage, or other loss, whether caused by negligence or otherwise.

Medical Treatment Authorization – In the event of an emergency, I authorize The X-Perience Dance Company staff to obtain medical treatment for the participant. I understand that I am responsible for any medical expenses incurred.
Code of Conduct – I acknowledge that participants are expected to follow all camp rules and guidelines. Failure to do so may result in removal from the program without refund.

Photo & Video Release – I grant permission for The X-Perience Dance Company to use photographs and videos of the participant for promotional, educational, or marketing purposes, unless I provide written notice opting out.
By signing below, I confirm that I have read, understand, and agree to the terms of this waiver.
Signature*
Date*

MonthDayYear
Date

My Products*

Registration Fee

$50.00

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
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