Inspire Inclusion Dance Camp Registration
Tuesdays and Fridays June 21st- Aug. 6th 2019.
Open to Dancers with and without disabilities ages: 5-22.
100 Beatties Ford Road Charlotte NC 28216 (JCSU).
Email: camerindancer@yahoo.com or call 404 786 9690 for more info.
Email Address *
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Dancer's Name *
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Dancer's Age *
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Dancer's Date of Birth *
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DD
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YYYY
Dancer's Shirt Size *
Address *
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Diagnosed Disability (put n/a if your dancer does not have a disability). *
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Allergies *
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Medications *
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Favorite Song *
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Does your dancer require any assistive technologies for dance class, if so what equipment is needed?
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Level of Self Care *
Toileting assistance needed? *
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Parent/ Guardian Name *
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Phone Number *
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Which classes will you attend (select all that apply) *
Required
Dietary Restrictions *
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EMERGENCY CONTACT INFORMATION #1 (Name, Relationship, & Phone number) *
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EMERGENCY CONTACT INFORMATION #2 (Name, Relationship, & Phone number) *
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PREFERRED HOSPITAL IN CASE OF EMERGENCY *
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NAME OF INSURANCE *
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DOES YOUR CHILD RECEIVE PRIVATE THERAPEUTIC SERVICES? If so please elaborate.
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