Dynamite Summer Dance 2022

Dancer’s Information
Dancer Name *
Member ID
Nickname
Date of Birth *

Month Day Year
Age
Summer Options *
Please provide any additional information that you think is important or may affect the dancer's ability to fully participate during Summer at DDF

Parents' Information

Parent/Guardian 1
Parent/Guardian 1 *

First Name Last Name
Relationship to Child *
E-mail *
Cell Phone *
Home Phone *
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent's Work/School Name *
Or enter N/A if not applicable
Parent's Work/School Phone
Parent's Work/School Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Where would you like to be reached while your child is at camp? *

Cell Phone Work Phone Home Phone
Parent Information

Parent/Guardian 2
Parent/Guardian 2 *

First Name Last Name
Relationship to Child *
E-mail *
Cell Phone *
Home Phone *
Home Address Same as Parent/Guardian 1?

Yes
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent's Work/School Name *
Or enter N/A if not applicable
Parent's Work/School Phone *
Parent's Work/School Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Where would parent/guardian 2 like to be reached while your child is at camp?

Cell Phone Work Phone Home Phone

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province
Primary Phone Number *
Secondary Phone Number *
Relationship to Child *
Emergency Contact #2
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province
Primary Phone Number *
Secondary Phone Number *
Relationship to Child *

Payment and Statement of Understanding

SUMMER AT DDF
Dynamite Dance Factory has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported. *
Type first and last name above to consent
Sign Document *
Date Signed *

Month Day Year

My Products

Company/Apprentice Co Camp $ 275.00

Quantity

BrownGirlTwirl June 21st-June 24th $ 150.00

10am-12:00noon

Quantity

HipHop Dance Camp 6-7yrs(JUNE) $ 175.00

5:45-7:45 Tuesday June 21st-Friday June 24th

Quantity

BrownGirlTwirl July 19th-22nd $ 150.00

10am-12noon Pink leotards, pink tights, pink ballet slippers

Quantity

HipHop Dance Camp 8-10(JULY) $ 175.00

5:45pm-7pm Tues-Fri July 19th-July 22nd Black leotard, black tights, sneakers, black jazz shoes

Quantity

Teen Six Weeks Program $ 185.00

Let's DANCE for Six Weeks of Summer! Every Monday June 13-July 15 from 6pm-8pm. CAlling all pre-teens and teens 11 and UP! Needed:Black leotard, black bottoms, sneakers, water!

Quantity

Tutus & Tumbling $ 75.00

Join us. For SIX WEEKS OF SUMMER! Every Tuesday from June 21st-July 26th! 4:15-4:45 Any gymnastics unitard of choice, pink ballet slippers

Total $ 0.00

Credit Card

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Dancer’s Information

Parents' Information

Parent Information

Emergency Contacts/Authorized Pickup

Medical / Health Information

Additional Medication

Payment and Statement of Understanding

Credit Card