Jingle Belles Mom's Day Out Clinic

Camper's Last Name *
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Camper's First Name *
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Parent/Guardian's Camper's Last Name *
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Parent/Guardian's Camper's First Name *
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Parent/Guardian's Email *
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Address: *
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Phone Number: *
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Physician's Name/Phone: *
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Student's School/Grade Level *
Check who you would like your child's picture with: *
How are you paying? *
Last Name on Check & Check Number (if applicable)--$60/made out to Anderson High School with "Belles" in the memo line. Attention Kayla Orton, 8403 Mesa Drive, Austin TX 78759.
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We cannot guarantee that we will receive any checks mailed after December 2nd. Online payments through School Cash Online can be made up until noon on December 6th. All payments must be received by December 7th, the day of the clinic. Any check received after 12/7 will be voided. Please bring proof of payment for all online payments to check in. All payments are non-refundable. *
Required
Check to agree with the following terms: GENERAL RELEASE: There are no refunds available. I, the parent/guardian of the camper associated with this registration, do hereby acknowledge and grant permission for my child or children listed above to participate fully and without restriction in the physical activities of the clinic identified above. On behalf of my heirs and assigns, I hereby release, indemnify and waive any and all claims I may or may not have against Anderson High School, the Trojan Belles, the dance directors and any parent or student instructors participating in the instruction or implementation of the dance clinic or camp, from any claims, physical and emotional, including bodily injury or illness that may be sustained in connection with attending the camp and with participation in any and/or all camp activities. I hereby give my permission to the Clinic Director to provide and/or seek medical attention or treatment that may be deemed necessary to insure the well-being of the named child. The director will attempt to contact me prior to administering/ seeking non-emergency medical attention. Please identify any medical limitations or allergies your child may have that the camp needs to be aware of (including allergies to medications and foods). PHOTO PERMISSION: I give the Trojan Belle director and dance clinic volunteers or other designated personnel permission to photograph my child during the dance clinic for media publications, flyers, video presentations, yearbook and web page material that promotes the Trojan Belles. *
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I understand that I am responsible for sending my child with a nut free lunch and a nut free afternoon snack. *
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Is there anything else we should know about your child?
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