Summer Registration

SSOD SUMMER REGISTRATION
Name_____________________________    DOB____________  Age as of July 1st _________
Please check all that apply:
Jump Start ______    Intensive week 1 _____    Intensive week 2 _____
Junior Intensive week 1 _____    Junior Intensive week 2 _____

Parent/Guardian __________________________    Relationship to student ________________
Address_____________________________________________________________________
Phone __________________________     Alternate Phone ___________________________
e:mail ____________________________

Parent/Guardian __________________________    Relationship to student ________________
Address_____________________________________________________________________
Phone __________________________     Alternate Phone ___________________________
e:mail ___________________________
Our principle methods of communication are e:mail, text, and our website
Please include below the names and phone numbers of anyone authorized to pick up the student:
____________________________________________________________________________
____________________________________________________________________________
Please list any allergies or special needs the student has:
____________________________________________________________________________

I hereby agree to save and hold harmless Shepherdstown School of Dance and the instructors thereof from all liability for loss, damage, or injury to persons or property, which may arise out of participation in Shepherdstown School of Dance programs, or use of Shepherdstown School of Dance facilities.
Parent or legal guardian__________________________ Signature_______________________
Date _________________

I, __________________________________ (Parent/Guardian Name),  do / do not (please circle one) give consent to Shepherdstown School of Dance to use my child's photograph taken in connection with school activities, for the purpose of, but not limited to, promotional content in publications, videos, and audio, or other media.
Signature of legal Parent/Guardian ________________________________ Date ___________
Relationship to child______________________ Child's name ___________________________

Shepherdstown School of Dance
400 South Princess Street (physical location)
150 Steamboat Run Road (mail only)
Shepherdstown, WV 25443
Emily Wanger Romine, Artistic Director 304-886-8398
Mercedes Prohaska, Managing Director 304-264-1832

TUITION IS NON-REFUNDABLE
please add 7% sales tax to your tuition

For registrations received after June 1st please include a $15 registration fee
Thank You