Spring Dance and Movement WorkshopMay 21, 2011

Parent Name: _________________________________

Email: ________________________________________

Cell Number: __________________________________

In Case of Emergency: ___________________________

Child #1 Name: ______________________ Grade in Fall 2011: __________________

___Pre-K -3rd Grade Session (10:30 am-12:30 pm) ___4th-8th Grade Session (12:30 pm-2: 30 pm)

Child #2 Name: ______________________ Grade in Fall 2011: __________________

____Pre-K through 3rd Grade Session (10:30 am-12:30 pm) ____4th-8th Grade Session (12:30 pm-2: 30 pm)

Child #3 Name: ______________________ Grade in Fall 2011: __________________

____Pre-K through 3rd Grade Session (10:30 am-12:30 pm) ____4th-8th Grade Session (12:30 pm-2:30 pm)

Cost: $15.00 per child ($10 each for multiple children in a family)

I am authorizing my child’s participation in The Studio’s Spring Workshop. I know of no mental or physical problems, which may affect my child’s ability to safely participate. The staff is authorized to attend to any health problem or injury, which may occur while in the workshop. I understand that my child must have current and active medical insurance before he/she can participate. Neither my child nor I will hold The Studio or it’s staff liable for any injuries or expenses related to injuries while my child is participating in the workshop. I have read and understand the terms described above. I authorize my child to participate in The Studio’s Spring Workshop.

___________________ Parent Signature _________________ Date

Please mail registration to:The Studio

15035 SE 124th AveClackamas, OR 97015

Please make checks payable to:Jessica Elliott