SUMMER CAMP 2019 REGISTRATION FORM
Unbound Dance Academy
1181 Hooksett Road Hooksett, NH 03106
_________ Princess/Pirate Camp (ages 4-7) JULY 15-19 8:30am-4:00pm cost: 225.00
_________ American Girl Dance Camp (ages 6-9) JULY 22-24 9:00am-12:00pm cost: 140.00
__________ Pinocchio: A Musical Theater Experience (ages 8-15) JULY 29 - AUGUST 2 8:30am-4:00pm cost: 225.00
_________ Dance Explosion Camp (ages 12-16) AUGUST 12-16 8:30am-4:00pm cost: 225.00
________ Senior Kick Up! (ages 11+) AUGUST 5-7 5:00pm-8:00pm cost: 140.00
STUDENT NAME: ___________________________________________________________________ DATE OF BIRTH: ________________________
ADDRESS: _______________________________________CITY: _____________________ZIP: ____________________
TELEPHONE: _____________________________ EMAIL: _______________________________
Are there any special needs/medical conditions? YES NO If Yes, Please Explain:
Who should we contact in case of emergency? ____________________________ Telephone: ______________________
I, the undersigned, do hereby waive all claims against the owner,, instructors, and assistants, individually or otherwise, of Unbound Dance Academy LLC for any injuries he/she may sustain while attending or participating in said programs. In the event that my child sustains an injury requiring immediate medical attention, I understand that Unbound Dance Academy, LLC. will make every reasonable effort to contact the individual noted above. However, in the event that the emergency contact cannot be reached, I do hereby grant Unbound Dance Academy LLC. the authority to administer first aid and/or contact emergency personnel.
Signature (Parent or Guardian)
PHOTO RELEASE: Unbound Dance Academy LLC may take photos or video to promote the studio. Photos may be published in our program literature, on our website, or used on local television stations or in local newspapers. Please check one of the following and sign below.
________ I give permission for photos/videos to be taken.
________ I do not give permission for photos/videos to be taken.
Signature (Parent or Guardian) Date