End of Summer Arts Intensive Registration
Participant Information
StudentName
*
First Name
Last Name
Student Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
Emergency Contact
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant
Workshop Selection
Workshop Selection
Modeling Bootcamp - $25
Dance Intensive - $25
Full 4-Day Intensive - $50
Medical Information
Medical Conditions, Allergies, Medications or Accommodations
Photo /Video Release
*
Yes
No
Liability Waiver
*
I agree to the Liability Waiver.
Information Certification
*
I certify the information above is accurate.
Electronic Signature
Questions or Comments
Continue
Continue
Should be Empty: