Summer 2021 Registration Form
Total Page：16
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Summer 2021 June 3 - July 29 Student Name _______________________________________________ Age___________ Students MUST be entering the Gender _____ DOB ______________ School________________________ Grade_______ grades below in Fall 2021 Address___________________________________________________________________ Summer Program Grades Price ✓ City_______________________________________ State______ Zip ________________ CHARLIE BROWN June 3 - June 25 1 - 5 695 Parent/Guardian CELL during class times (_________)____________________________ 9:00 AM – 1:00 PM nd Mother Name______________________________ CELL (______)___________________ 42 STREET June 7 - July 3 6 - 12 950 Email_____________________________________________________________________ see rehearsal schedule Father Name_______________________________ CELL (______)___________________ CAMP Broadway KIDS July 6 - July 16 K - 9 695 Email_____________________________________________________________________ 9:00 AM - 4:00 PM Marital Status M D S W Child Resides with Mother___ Father___ Both___ Other___ CAMP DISNEY July 19 - July 29 K - 9 695 Person Responsible for payment: ______________________________________________ 9:00 AM - 4:00 PM Student Email______________________________________________________________ Registration Fee Included! Included! Student Cell (_________)_____________________________________________________ T-Shirt GRAND TOTAL Family Physician ______________________ Physician Phone ______________________ List Allergies/Medical _______________________________________________________ Along with his or her participation in our REGISTRATION: This studio does not issue refunds or credits due to illness, summer program(s) your young star vacations, religious observances, extended travel or for any other reason deemed non- will receive one of our signature refundable by StarStruck. StarStruck t-shirts! TUITION AND FEES: The signer of this contract (“I”) understands that tuition is a (Circle one) semester fee and must be paid before student attends camp as per the payment option Shirt Size: selected. I understand that payment may be made by: check, cash, or credit card. I CS CM CL got talent? understand that any returned check will incur a $35.00 fee to cover bank charges AS AM AL AXL incurred by StarStruck. I understand that if a check has been returned for non-payment, ☐ only CASH payments will be accepted for the remainder of the season. I understand Received Shirt __________ that students will not be able to participate in camp if tuition is not paid. I understand that there are no refunds if a student withdraws from a camp/production. I understand RELEASE/LIABILITYthat correspondence WAIVERfrom StarStruck: In consideration will be of made the benefits via email. derived The from Studio StarStruck, does students/guardians not send waive all claims arising from dance instruction, rehearsal, training and performances at StarStruck and/or any other designated off-site performance space, whether caused by negligence or otherwise, and for bodily injury, property damage or loss or otherwise, that students may incur against StarStruck, its successors and assigns, its officers, directors, shareholders, employees and agents, and their heirs, executors, and administrators. Additionally, students/guardians waive all claims arising out of (1) the act of being transported to and from such activities, or (2) other StarStruck events or functions. The student(s) named on this contract does voluntarily participate in any/all StarStruck activities and I understand that certain risks are involved and waive the right to any legal action for any injury sustained at StarStruck resulting from normal dance activity or any other activity conducted by the student(s) before, during or after class time. I certify that the student(s) listed on this contract is(are) in good health and capable of participating in all the activities and classes. I am aware that StarStruck may videotape or photograph students. StarStruck is hereby granted permission to use this media in brochures, web site, posters, advertisements and/or other promotional materials for StarStruck. Permission is hereby granted for StarStruck Academy and Theatre to copyright such photographs in its own name. PARENT/GUARDIAN SIGNATURE ____________________________________________________________________________________________ DATE _____________________________ StarStruck Internal Use Only: Paid_________________ Date_________________ Amount due (if applicable)_________________ ☐ Registered Online ☐ SCH ____________ Cash_________________ Check_______________ CC (Last 4 digits)_____________________ MC AMEX VISA DISC ☐ DSP _______________ ☐ QB _____________ Academy: 772.283.2313 StarStruckFL.org Box Office: 772.283.7787 [email protected] .