6PDC Summer Camp Registration Form 2019
*Note: Summer Camp is held from 8:00 am - 4:00 pm daily. Campers may be dropped off as early as 7:30 pm each day. Extended care is also available from 4:00 pm - 6:00 pm to accommodate parent/guardian work schedules.
Email address *
Student Name *
Your answer
Student Age *
Your answer
Student Birthdate *
MM
/
DD
/
YYYY
Parent Name *
Your answer
Mailing Address *
Your answer
Telephone *
Your answer
Emergency Contact: Name & Telephone *
Your answer
How did you hear about us? *
Required
Registration Fee *
Required
Week *
Required
Extended Care
T-Shirt Size: *
As the parent/guardian completing this application I agree to allow 6th Position Dance Company to use my child's image in connection with promotional advertising. *
I authorize 6th Position Dance Company to automatically deduct the weekly tuition by credit card on the Sunday prior to the start of each camp week. *
Credit Card Type *
Credit Card Number *
Your answer
Expiration Date *
Your answer
Security Code *
Your answer
Name as it appears on the card *
Your answer
Credit Card Billing Address *
Your answer
Release and Authorization *
Child Physician: Name & Telephone *
Your answer
Insurance Company & Policy Number *
Your answer
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