DDF 2021"Love Yourself" Retreat Registration

Camper's Information
Camper Name *
Member ID
Nickname
Date of Birth *

Month Day Year
Age
Retreat Registering For? *
Please provide any additional information that you think is important or may affect the dancer's ability to fully participate in the retreat.

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 *

My Products

"Love Yourself" Retreat $ 75.00

Quantity

Chaperone Fee $ 30.00

Quantity

Total $ 0.00

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
Camp Director Name and Contact Info
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