Summer Camp Enrollment 2022

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Student Name *

Last Name *

Birth Date *

YYYY

Address *

City *

State *

Zip Code *

Choose Camp or Workshop *

Tuition *

Dance Camp $125

Workshop $60

Shirt Size (Dance Camp ages 3-6)

Parent/Gaurdian Name (First, Last) *

Phone *

Email *

Emergency Contact (Name) *

Emergency Contact (Phone) *

Credit Card *

Name (as it appears on the card) *

Card Number *

Exp. Date *

Billing Zip Code *

CSV Number *

Media Release: As the legal parent or guardian, I release all team and/or individual photographs, videos, quotes, interviews and/or other “media” of the participant and/or the undersigned to Relevé Performing Arts. *

I acknowledge

Required

Release Of Liability: As the legal parent or guardian, I release and hold harmless Relevé Performing Arts, its’ owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises of any premises under the control and supervision of Relevé Performing Arts, its’ owners and operators or in route to or from any of said premises. *

I acknowledge

Required

Medical Emergency: The undersigned gives permission to Relevé Performing Arts, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or condition and/or declare the participant to be in good physical and mental health. *

I acknowledge

Required

I request that our doctor/physician _________________________________ be called and that my child be transported to _________________________hospital. Please include the physician's phone number, name and hospital name. *

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