Registration Form Summer Camps printable pdf download

Registration Form Summer Camps 2014

Student’s Name

__________________________

Nickname ______________________

Date of Birth __________ School _______________ Grade____ Phone # (home)____________

_______________________________________ Military_________

Street Address

Parent’s E-mail address _______

________________

Apt. #_____ City______________ Zip Code______

Mother’s /Guardian’s Name _________________ Cell Phone # ___________________________

Place of employment _______________________Work/Alt. Phone # _______________________

Father’s/Guardian’s Name __________________ Cell Phone # ___________________________

Place of employment ______________________ Work/Alt. Phone # _______________________

Emergency contacts: Name _______________________ Phone # __________________________

Name _______________________ Phone # _________________________

Years/Description of Training:______________________________________________________

_______________________________________________________________________________

Camp student is enrolling in:

Dates:

(use back of this page for additional classes)

____________________________________

_____________________________________

____________________________________

_____________________________________

____________________________________

_____________________________________

____________________________________

_____________________________________

Additional Information (Please include information that will help us best serve the student, such as

any special needs or concerns):______________________________________________________

_______________________________________________________________________________

Allergies (please list all)___________________________________________________________

How did you hear of Heartbeats Music and Dance?_____________________________________

I understand that dance students take dance classes at their own risk and that neither Heartbeats nor any instructor

is liable for any injury a student may sustain during those classes. By registering with Heartbeats, I grant

Heartbeats the right to use images/photographs taken during class or other Heartbeats activities for advertising or

promotional purposes. It is my responsibility to keep aware of studio information by reading notices sent home

with my child and/or reading notices posted in the studio. I have read the Heartbeats Policies and Procedures and I

understand, and agree to, the tuition rates, refund policy, withdrawal policy, late fees, class schedule, and other

policies outlined therein.

Student’s/Parent’s (if student under 18) Signature:

Please mail registration form & payment to:

Heartbeats Music and dance, 8060 RollingRd, Springfield, VA 22153

Registration Form Summer Camps