Mini Dance Fusion Summer Intensive 2023

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May 31st-June 3rd
Registration/ Medical Release Form

MINI Intensive with Professional Guests; Adam Parson, Ryan "Bosco" Baker and Tanner Blee
Ages 6-8 years ***Wednesday-Saturday are Mid-Morning classes, 11a-1:45p (tentatively) with an informal showcase on Saturday, June 3rd at the studio at 4:00p. Four-day Mini- Camp is $225 with pre-registration and a $100 non-refundable deposit by March 1st, or $250 if registering after April 1st. Remaining ($125) due April 15th.

(EACH STUDENT NEEDS A SEPARATE ONE)

Email *

Student: First, Last Name *

Date of Birth *

YYYY

Age, M/F *

Parents’ Name: First, Last name *

Contact Phone and Alt. Phone (please include who's phone # it is) *

Mailing Address *

Email Address *

Dance Studio Affiliation *

Dance Studio Phone # *

Dance Studio Email *

Dance Studio address *

Current classes taken *

Number of years dance training *

List any health, medical, or physical problems and/ or conditions below and explain limitations. *

Family Doctor’s Name *

Family Doctor’s Phone # *

Alternate Emergency Contact Name/ phone: *

Please select one of the following options: *

$100 deposit due on March 1st to secure my child’s spot and pre- registration discount, balance due 4/15

I have enclosed payment of $250 after April 1st for the full amount.

I authorize Absolute Dance to charge my card and use my child’s photo, video recording, and/or written statements for advertising, display, or other use, without review by, or compensation to, participant or parent/s. Absolute Dance is not responsible for participants’ lost, stolen, or damaged personal belongings. ABSOLUTE DANCE IS NOT RESPONSIBLE FOR INJURIES ON THE PREMISES. By signing below, I acknowledge that dance, like any other physical activity, can result in injury, and therefore, I will not hold ABSOLUTE DANCE and their associated staff liable for injuries incurred during class or on the premises. I understand and agree that I am liable for the full tuition amount indicated on any Absolute Dance materials, including any late charges, fees, or interest, even in the event of the student's withdrawal or dismissal from the program before it is complete. I understand that Absolute Dance does not offer any tuition refunds for missed classes, withdrawal, or dismissal from the program. Account credit will be ONLY be given with Director's approval, if a student must withdraw due to severe illness or injury, to be eligible they must supply a doctor's note with the request to withdraw from the program. Parent/Guardian Signature Date *

A copy of your responses will be emailed to the address you provided.

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