Camp Registration
THE DANCE FACTORY, INC.
5669 Austell-Powder Springs Road
Austell, GA 30106
Form of payment [] Check __________# [] Money Order ____________#
Child’s Name _____________________________________________________
DOB ___________ Age_____ Current School Grade________________
Parent/Guardian’s Name ___________________________________________
Address______________________________ City ____________________
Work Phone (Mom)______________ Work Phone (Dad)________________
Zip Code __________ Home Phone _______________ Cell______________
Medical Condition/Allergies: ___________________________________________
Emergency Contact Information:
Contact Name: _______________________ Phone #: _____________________
Child’s Physician & Phone: ____________________________________________
Camp Hours:
Junior Camp9:00am – 2:00pmMonday - Friday
Senior Camp4:00pm – 8:00pmMonday – Friday
Extended Care Hours
[] Check here if you think you will be interested in using the extended care
Hours (7:30–9:00am & 2:00–6:00pm) Additional
charge of $20.00 per day and snacks will be provided.
Release from Liability
I do hereby release The Dance Factory, Inc. and its staff from any liability occurring on or around studio premises, or at any other function held at other locations in connection with the dance classes in which the student(s) named above is/are enrolled. I declare that the student(s) above is/are in good health and can participate in dance education classes. Given the nature of dance classes, and with the knowledge that injuries sometimes might occur, I have taken the necessary steps to obtain accident, health, or hospitalization insurance, which would cover any sustained injury. In the event of an injury or emergency when I cannot be contacted, I give my permission for you to obtain medical services for the student(s) named above.
Signature of Parent or Guardian___________________________Date___________
Please check the studio or website for summer camp week dates.
Click Here to Download Form
Print