Name: __________________________________________________________________ Age: ________________

Address: _____________________________________________________________________________________

DOB: _________________________________ e-mail: _________________________________________________

Mother’s name: ______________________________________________ Cell phone: ________________________

Father’s name: ______________________________________________ Cell phone: ________________________

Home phone: _________________________________ Emergency contact: _______________________________

Emergency contact phone number: ________________________________________________________________

Who is authorized to pick up?: ____________________________________________________________________

Allergies: __________________________________________ Medication: _________________________________

Please list the camps you are registering below:

I, ______________________________ agree to pay $ _____________________ to For A Dancer, Inc. for the camp (s) listed above. I understand that For A Dancer, Inc. and its staff are not responsible for lost or stolen items, as well as, any injury that may occur on or in the facility. I agree to the payment terms. I give my permission to For A Dancer, Inc. and any member of its staff to call an ambulance in case of emergency that cannot wait for parent, guardian or emergency contact to be notified. In the event of such an emergency, the parent will be notified immediately after the ambulance has been contacted. I have read and understand the studio policies and agree to abide by them.

_______________________________________________________ _____________________
Signature of parent / date

Please get your registration in early, camps fill fast!

Please return registration with payment to:

For A Dancer, Inc.
c/o Rachel Good
636 Galina Way
Warrenton, VA 20186

Or drop it by the studio…
85 West Lee Hwy, Warrenton.

Thank you for making us a dance success!