DANCE CAMP
AT
BAYSIDE SCHOOL OF DANCE
(401) 435-4908
DANCE DIRECTORS – BEVERLY PARSONS, ERICA DE COSTE, REBECCA STEFANKO and KAREN BERNIER
DATE __________________
NAME OF CHILD____________________________________________
AGE _______
ADDRESS ________________________________________________________________________
PHONE_________________________________________
NAME OF PARENT/LEGAL GUARDIAN _________________________________________________
ADDRESS _________________________________________________________________________
PHONE ________________________________________
DOCTOR’S NAME _____________________________________________
ADDRESS _________________________________________________________________________
PHONE _________________________________________
EMERGENCY PHONE NUMBERS OF FRIENDS AND RELATIVES
NAME _______________________________________________
ADDRESS ___________________________________________________________________
PHONE ______________________________________________
NAME _______________________________________________
ADDRESS ___________________________________________________________________
PHONE _____________________________________________
ANY ALLERGIES OR MEDICAL CONCERNS THAT I SHOULD BE AWARE OF:
IN CASE OF EMERGENCY, AND I AM UNABLE TO BE REACHED, BEVERLY PARSONS, KAREN BERNIER, REBECCA STEFANKO AND/OR ERICA DE COSTE, HAS MY PERMISSION TO ACT ON MY BEHALF SHOULD A MEDICAL DECISION NEED TO BE MADE CONCERNING MY CHILD,
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THIS FORM IS VALID ONLY FOR THE FOLLOWING DATES: PLEASE CHECK ONE.
AGES 4-6 JULY 17th – July 21st 2023 9:00AM – 11:30AM PRICE $90
AGES 7 - 11 July 24th – July 28th 2023 9:00AM – 2:00PM PRICE $180
SIGNATURE OF PARENT/LEGAL GUARDIAN
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