FLORIDA DANCE WORKSHOP        Annual Fall Registration Fee $12.00 per student                                                                                                                          

(Please Print Student information Clearly)

 

LAST NAME                                                         FIRST NAME_____________

 

STREET ADDRESS                                                                                              AGE 

 

TOWN or CITY &  zip______________________________________________

 

EMAIL_________________________________HOME PHONE__________________    

 

OTHER PHONE:                                EMERGENCY CONTACT_____________________

 

NAME OF PARENT(S) OR GUARDIAN:_____________________________________________________

 

ARE there any medical conditions we should be aware of?  ____YES       ____NO

 

<If YES, please state and include any instructions on back of this sheet…………>

 

Previous Dance Experience    ____Yes         _____NO     

 

<If YES, please list name of school, teachers, styles, and number of years on back of this sheet ...>

 

FALL CLASS CHOICES:

 

CLASS                                                           DAY                                              TIME_____

 

CLASS                                                          DAY                                              TIME______

If more than two, use back of this sheet.................................................>

 

Dancepower Summer Arts Camp (10 am to 2 pm, Full week $150)         _____Yes    

 

Summer Technique Course(s)   (4 wks, $35 ea) 

 Course                                                             Day / Time                            

 Course                                                             Day / Time                            

 Musical Theatre Course (4 wks, $60.00)                Start Date:                                                         

…………………………………………………………………………………………………………………

Since participation in any physical activity includes some element of risk, I release the owner/director/ teachers of Florida Dance Workshop from any and all liability of loss, or personal injury, that may occur at the Workshop facility, or at any performance venue.  If I cannot be reached, in the event of a medical emergency, I give permission for emergency medical treatment.  I understand that photos and recordings of participants become the property of Florida Dance Workshop and its director and may, therefore, be used for future publicity.  I further understand that membership requires following policies as outlined in the school brochure and on the Showtime Instruction Sheet and I agree to following those policies, including giving

 a written notice of discontinuation of classes.

 

SIGNATURE                                                                            TODAY’S DATE______________

(Parent or Legal Guardian, if under 18)

INSTRUCTIONS: Print and Mail this Signed FORM, with Registration Fee and /OR Course Tuition, to: Michelle Labousier,  341 Lenoir Street,  Port Charlotte FL 33948 Thank you and welcome!

Please note: If this page does not print properly, please call or email us and we will be happy to send you a form as an attachment via email, or by way of snail mail.

 

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