Name *

Age *

Address *

Phone *

Emergency Contact *

TShirt Size *

I, THE PARENT/LEGAL GUARDIAN OF THIS PARTICIPANT IN STUDIO 201 DANCE PROGRAM, HEREBY AUTHORIZE THE STUDIO 201 STAFF TO OBTAIN WHATEVER MEDICAL SERVICES DEEMED NECESSARY IN THE EVENT THE PARTICIPANT SUSTAINS AN ILLNESS OR INJURY IN MY ABSENCE. THIS AUTHORITY INCLUDES CONSENT TO ANY MEDICAL PERSONNEL OR FACILITY TO RENDER CARE AND TREATMENT AUTHORIZED BY THE STAFF. THE STUDIO 201 STAFF WILL NOT BE RESPONSIBLE FOR INJURY, THE COST OF MEDICAL TREATMENT OR TRANSPORTATION. *

I understand that I will have to pay the camp fee before my dancer can attend. *