6PDC Winter Dance Camp 2024-2025 Student Name* First Last AgeBirthdate* MM slash DD slash YYYY Today’s Date* MM slash DD slash YYYY Parent/ Guardian Name*Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zipcode Day Phone:*Evening Phone:Email*Used to send you a receipt and important updates Emergency ContactName* First Last Phone*Authorized Pick Up List*Please describe any allergies, learning or physical disabilities your child may have. Leave section blank if the latter doesn’t apply.ENROLLMENTPlease check the Week Session(s) your child will be attending:* Session 1: December 26th -27th (Thursday-Friday) 9:00 am - 4:00 pm (extended hours 7:30am-6pm) Session 2: December 30th-3rd (Monday-Friday) 9:00 am - 4:00 pm (extended hours 7:30am-6pm) Processing Fee*This field is hidden when viewing the formWaiver I have read and agree to the Waiver and Release. Registration Total $0.00 Please Note: Payments are Non-Refundable!PAYMENT METHODSelect Your Payment Method*PayPal CheckoutCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name
