Student’s Name_________________________ Age_____Sex____ Parent’s Name____________________ Home Phone______________________ Business Phone____________________ Address__________________________ City______________St____Zip_______ Email Address_____________________________ Class/Camp Code:
1st choice______2nd choice_______ I, ___________________________________
have enrolled my child __________________
in a program of physical activity including but not limited to creative movement and or Ballet/Jazz. I hereby affirm that my child is in good physical condition and does not suffer from any disability that would prevent or limit his/her participation in this program. In consideration of my child’s participation in Fairy Tales in Motion, I ______________________________
for my child, myself, my heirs and assigns release Fairy Tales in Motion (it’s members and owners) and Belle Haven Country Club, (It’s members and owners) from any claims, demands and causes of action resulting from any participation in the dance program. ____________________________________
Parent or guardian’s signature and date Please mail this form along with check for payment in full to: Jan Taylor
P.O. Box 51
Brookeville, MD 20833-0051
301-253-0484 |
