camp

							              SUMMER CAMP 12 ANGIE’S DANCE CENTER

                                       SHAKE IT UP
                                      EVENT: 6/25-6/27 4PM-6PM

                                            COST: $60

NAME ___________________________________ AGE ____________

BIRTHDATE _________________

CONTACT NUMBER_________________________ PARENT NAME _________________

Health info/problems: __________________________________________________________

I/we understand as guardian of this student that the dance center cannot be held responsible for
any accident, injury or harm that might come to my child as a result of factors beyond the
center’s control. I understand that competent instructors supervise all classes, monitored by adult
staff in order to provide a safe, loving learning environment

Signature of guardian: ________________________________ date ______________

Office use:

Amount received $_________ Cash/check/cc _____________

Date ______________ item paid for ____________