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Huntington Dance Theatre - Summer Dance Workshop 2008 Registration Form (Please print and complete this form for registration) STEP 1: Student/Family Information (complete one form per child & print clearly) How did you hear about us? Flyer-Web site-Newspaper-Friend-Other _________ Student Name: ____________________________________________________ Boy: ___ Girl: ___ Birth date: ___/___/___ Mailing Address: ________________________________________________________________ (Street) (City) (State) (Zip Code) Telephone: ________________(Cell) __________________________________ Dance Training: Type: ____________ # of Years ___ Where: _______________ Parent/Guardian Name (s): __________________________________________ E-Mail Address: ___________________________________________________ Emergency Name: ___________________________ Telephone: ____________ Name(s) of sibling enrolled: __________________________________________ Known Medical Conditions: __________________________________________ (Please attach any supporting information HDT should be aware of) STEP 2: Class Information & Acknowledgment TUITION & FEES 1 week June 23 – June 27, 2008 Ages 7 – 9, $75.00 All other levels, $140.00 Discount (10% discount for families with 2 or more siblings participating) *Make check payable to Huntington Dance Theatre or HDT (1/2 must be received with registration to reserve space, no refunds) Total Due...................................$ __________ Discounts (if applicable)……….. ___________ Less Amount Enclosed ............. ___________ Balance Due by 1st Class……..$___________ As legal guardian of the above named student, I certify that he/she is physically fit to perform in all programs at Huntington Dance Theatre, is not currently under medical care, and is not receiving medication for any condition which would or may limit participation in any way, except as listed above. I do hereby give approval to allow participation in any and all activities. I assume all risks and hazards incidental to the conduct of the activities and transportation to and from activities. I understand that these risks can never be totally eliminated, even under the supervision of properly trained and qualified instructors. I do further release, absolve, indemnify and hold harmless Huntington Dance Theatre, its dancers, instructors and/or other staff members from the responsibility of any injuries sustained by any student during the course of instruction or in performance in which he or she may participate in. I hereby waive all claims against the organizers, sponsors or any supervisors appointed by them. Huntington Dance Theatre DOES / DOES NOT (circle one) have my permission to use photos of my child which may be used for publicity. I have read and understand this Huntington Dance Theatre Registration Form ___________________________________________ _____________ (Legal Guardian’s Signature) (Date) STEP 3: Mail or deliver this form along with registration fee to Huntington Dance Theatre, PO Box 2211, Huntington, WV 25722. Cash payments must be made in person, 412 8th Street, Huntington, WV 25701. Please call if you have any questions on completing the form or the program, 304-522-4230 HDT Office Use Only Date: ____________ Amount Paid: ____________ Check #/Cash:___________ Miscellaneous: |