Customer Information and Registration Form

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Shavuot Breakaway Camp June 12th 11:15-12:15pm at Holy Blossom Temple

Email *

Name of Parent/Guardian *

Name of Child *

Birthdate of child *

YYYY

Parent Cell Phone Number *

Emergency Contact *

Special Needs/Medication

Date of enrolment

Hours 11:15am-12:15pm

June. 12th

Required

Authorized Pick Up Names

Allergies- Please state below if your child has any allergies

I agree to allow any photographs taken in connection with L’Dance activities to be used for the promotional
and advertising purpose of L’Dance (shared on our social media).
*

Yes

Liability Waiver and Consent (type your name in response box as digital signature) *

I understand that participation in all activities, exercises, and dances carry an inherent risk of injury and are
undertaken at personal participant risk. I understand that there is a risk of personal injury and with this
knowledge agree to indemnify and hold harmless L’Dance, its principals, instructors, employees and students, from all liability, damages, expenses and losses whatsoever caused or contributed to by any accident or injury, known or unknown, to the child, or to third persons, and to anyone who may be with the child, during the course of the child’s participation at camp.

I understand that all payment is final and any missed days will not be refunded.

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