Winter Camp Registration Form Winter Camp Registration 2016/17 Please fill out this form to register your child for camp! After completing the form you will be prompted to make payment. We are so happy you are joining us for a ROCKIN' WINTER CAMP IN SANTA MONICA! Student's Name* First Last Student's Birth Date* MM DD YYYY Child's Age*GradeChild's Gender*Child's School*Parent #1 Name* Parent #1 Phone (Cell)*Parent #2 Name* Parent #2 Phone (Cell)Home Phone NumberBusiness Phone NumberEmail Student's Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country EMERGENCY CONTACT NAME (Other than parents)* Relationship to Student*Phone #*How did you hear about us? A friend? Has your child taken a dance class at school? Had a birthday party? Did you read an advertisement? Let us know names & places please. We'd love to hear! Maybe your child's dance instructor will be at camp! Thanks!* Session 1: December 19-23, 2016Session 1: ($355.00)Joslyn Park Auditorium 633 Kensington Rd. Santa Monica, CA 90405 9A-3P Session 2: January 3-6, 2017 (Tuesday- Friday)Session 2: ($300)Joslyn Park Auditorium 633 Kensington Rd. Santa Monica, CA 90405 9A-3P (Tuesday - Friday) REGISTRATION FEE*$25 Registration FeeREQUIRED FOR MATERIAL FEE OF VIDEO EDITING AND REGISTRATION PROCESSINGPlease list any allergies, medication, health concerns We want your child to have the best possible experience at our camp, please share with us more about your child. List any information that is relevant to taking the best possible care of your child’s health: Allergies? Asthma? Health Concerns? Medication? Previous Injuries? Special Needs? Please put sunscreen on your child every morning before camp. We encourage children to bring their own sunscreen with them, however we will supply sunscreen throughout the day as well.* I give the staff permission to apply my child’s sunscreen. I DON'T give the staff permission to apply my child’s sunscreen. 2016-17 Winter Camp Enrollment Agreement (Please Read Carefully)* I have read, agree and understand all of the Registration Information and the Enrollment Agreement. • My child(ren) has my permission to attend camp, under the supervision of the Funky Divas & Dudes LLC. • I understand that a late charge of $25 applies if my child remains after 3:00pm sharp. • Funky Divas & Dudes LLC may use my child’s photograph/ likeness in promotional materials. • Any questions I have about Funky Divas & Dudes Camp has been answered to my satisfaction. • I understand there are absolutely no refunds or make-up days. • I agree to pay all tuition and fees set forth for Funky Divas& Dudes Camp. • If Funky Divas, in judgment believes my child(ren) requires medical attention, Funky Divas & Dudes LLC has my authorization to obtain such medical care from a licensed hospital or physician as they deem necessary. As the guardian, I will be responsible for all physicians, hospital and related costs so incurred. • On behalf of my child(ren) I voluntarily assume all risks of injury, loss, or damage that may be sustained and release and discharge Funky Divas & Dudes LLC, its officers, staff, employees, and residential hosts from all loss or damage and from any claim or demand on account of injury or death. • I agree to hold harmless, indemnify and defend Funky Divas & Dudes LLC, its officers, staff, employees and residential hosts for and from any and all liability, claims, expenses, demands, fees, judgments and/or damages arising directly or indirectly from my child(ren)’s participation in camp programs or at any time my child(ren) is on the premises of or premises used by Funky Divas, save and except claims arising out of the sole willful misconduct of Funky Divas. I will reimburse Funky Divas, it’s officers, staff, employees, agents and residential hosts for all expenses including reasonable attorney fees for all such claims made. • I hereby release Funky Divas & Dudes LLC, Dana Marie Lazzareschi & Kelly Lyans of any injury claims resulting from my child participating in the Summer Camp. I, the undersigned parent or guardian, grant permission to any physician, selected by the instructors to secure, at my expense, proper treatment, including but not limited to x-ray examination, anesthesia, medical and/or surgical diagnosis or treatment, and hospitalization if necessary for my child. • I have read and understand all of the Registration Information and the Enrollment Agreement.Total amount due $0.00 Click the "submit" button below to register your child. You will also receive an email with a payment option. Open that email and click the link provided to make payment. Thank you.NameThis field is for validation purposes and should be left unchanged.