Camp Registration

SUMMER CAMP REGISTRATION

Get ready for a summer of fun! Our summer camp is geared towards children ages 5-12.

Camp Dates: June 24th-August 23rd: End of the Summer Show: August 24th

Camp Hours: 9am-3pm, Morning Care 8am-9am, Aftercare: 3pm-5pm

Early Bird Tuition- Must be registered with registration fee and deposit paid by May 11th: $175 a week; $1575 for all 9 weeks

Standard Summer Tuition- Registered with registration fee and deposit paid after May 11th: $195 a week; $1755 for all 9 weeks

Extended Day: $30 a week; $270 for all 9 weeks

Nonefundable Deposit: 25% of full summer tuition (goes toward tuition)

Nonrefundable Registration fee: $55 (Includes MDA Summer Camp T-Shirt)

Tuition due dates: June 8th- 50% of remaining balance, July 20th- remaining balance

If you are registering more than one child, please complete a separate form for each.

TODAY'S DATE

CHILD INFORMATION

NAME

First Name

Last Name

AGE (Ages 5-12)

BIRTH DATE

YYYY

MEDICAL INFORMATION

Please list ALL medical conditions that we should be aware of. If none, please enter "NONE"

PARENT/GUARDIAN INFORMATION

NAME

First Name

Last Name

PHONE # (Cell)

(###)

###

####

STREET ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

EMAIL ADDRESS

YOUR RELATIONSHIP TO THE STUDENT

HOW DID YOU HEAR ABOUT US?

EMERGENCY CONTACT INFORMATION

Please provide the information below for the person you would like us to contact in the event of an emergency while your child is in dance class and we are not able to reach you.

NAME

First Name

Last Name

CONTACT NUMBER

(###)

###

####

RELATIONSHIP TO THE STUDENT

WAIVER AGREEMENT & SIGNATURE

I hereby release Monarch Dance Academy, Aliya Anderson, staff and students in any capacity for any liability due to injuries that may occur as a result of participation in camp at Monarch Dance Academy, or any event associated with Monarch Dance Academy. I understand that participation in this camp will involve rigorous activities. I am fully aware of any & all personal medical conditions. hereby certify that my dancer is physically capable and willing to participate in the enrolled class. Registration fees are non-refundable and non-transferable. Tuition is also non-refundable and non-transferable once a tuition period has started.

PARENT/GUARDIAN SIGNATURE

MEDIA RELEASE FORM

I hereby grant Monarch Dance Academy (hereinafter "MDA"), its agents, employees or other assignees permission to use my likeness in photograph, video, and/or audio recording in any and all of its publications or broadcasts, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of MDA and will not be returned. I hereby irrevocably authorize MDA to edit, alter, copy, exhibit, publish or distribute this photograph, audio, and/or video recording for purposes of publicizing programs affiliated with MDA or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph, video and/or audio recording. I hereby hold harmless and release and forever discharge MDA from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may acquire by reason of such authorization. I am at least 18 years of age and am competent to contract in my own name. I have read this release before I signing below and I fully understand the contents, meaning, and impact of this release.

SIGNATURE

DATE

PRINTED NAME

DATE

If the person signing is under age 18, there must be consent by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.

Parent/Guardian's Signature

Date

Camp Registration

SUMMER CAMP REGISTRATION

Extended Day: $30 a week; $270 for all 9 weeks

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