Customer Information and Registration Form
Passover Break Camp Apr.19- May.1 2024 Ages 3.5-11 at Holy Blossom Temple
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Email *
Name of Parent/Guardian *
Name of Child *
Birthdate of child *
MM
/
DD
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YYYY
Parent Cell Phone Number *
Emergency Contact *
Special Needs/Medication
Date(s) of enrolment
Hours 9:00am-4:00pm
 *
Required
Authorized Pick Up Names
Allergies- Please state below if your child has any allergies 
I agree to pay L'Dance via E-transfer to Ldanceclasses@gmail.com in the next 24hrs to secure my enrolment or this registration will be deleted/void. Please use the password 'dance22' and include your email in the notes. *
I agree to allow any photographs taken in connection with L’Dance activities to be used for the promotional
and advertising purpose of L’Dance (shared on our social media). 
 *
Liability Waiver and Consent (type your name in response box as digital signature) *
I understand that participation in all activities, exercises, and dances carry an inherent risk of injury and are
undertaken at personal participant risk. I understand that there is a risk of personal injury and with this
knowledge agree to indemnify and hold harmless L’Dance, its principals, instructors, employees and students, from all liability, damages, expenses and losses whatsoever caused or contributed to by any accident or injury, known or unknown, to the child, or to third persons, and to anyone who may be with the child, during the course of the child’s participation at camp.
I understand that all payment is final and any missed days will not be refunded.

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