DANCE CAMP Kindergarten and Up

Student Name ________________________________________ Age _____________Birth date_________

Parent’s Name Mother__________________________________Father____________________________

Address ____________________________________________________________Zip Code______________

Home Phone ___________________Parent Cell Phone 1 Cell Phone 2____________

Emergency Name and Number ___________________ E-mail: ________________________

*PLEASE CALL ME AT 724-745-9470 IF YOU HAVE ANY QUESTIONS*

PLEASE SIGN AND DATE WAIVER

I Understand that the dance instruction given to my child,_______________________,is a vigorous

Physical activity which may result in injuries to my child. In consideration of the enrollment of my child,

I hereby release the owners, directors, employees, affiliates and agents of The Lori Allen Dance Center

And the owners of the premises upon which any class, rehearsal or any performances is held from any

And all causes of action, claims for damages and expenses related to or arising out of any accident, injury

Or loss of property related to my child’s instruction or participation in any activity related to the

Lori Allen Dance Center. Signature______________________________ Date_______________

.

Where Children Can Reach Their Goals and Fulfill Their Dreams