HS Dance Dept - Kids Day Out/ Royals Mini Clinic Registration form
Clinic Date/Time: FRIDAY APRIL 26, 2024 8am-4pm for CA-Elementary students K-5th grade & Staff kids, 
Event Address: 7200 Paluxy Dr, Tyler, TX 75703, CAHS Upper Campus Dance Studio
Contact info: (903) 944-7835 ext: 445 or jbrosang@cumberlandacademy.com
Please fill out 1 form per child. Thanks so much
Email *
Child's First & Last Name *
Child's Age/Grade *
Parent's  First & Last Name *
Parent's Cell Phone Number *

MEDICAL RELEASE STATEMENT

I hereby give my permission for any and all medical attention necessary to be administered to my child. I understand and accept that the risk of injury is possible while participating in any athletic/ dance activities. I agree to accept full responsibility for any medical charges on my child’s behalf.  I release Cumberland Academy High School from any liability related to possible injuries. 

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Required
Does the participant/participants have any medical conditions, dietary restrictions or allergies we should be aware of?  *
1st  EMERGENCY CONTACT NAME & PHONE NUMBER  *
2nd  EMERGENCY CONTACT NAME & PHONE NUMBER  *
I understand that I must pay $35 registration fee upon arrival at 8:00am-9:00am. CASH ONLY                                 No cards or checks 

CA High School  Upper Campus                                        7200 Paluxy Dr. , Tyler Tx 75703 

Please contact Jennifer Brosang @ 903-944-7835 ext 445 or jbrosang@cumberlandacademy.com  with any questions

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A copy of your responses will be emailed to .
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