Adult Intensive Registration Form

Student Name *

First Name

Last Name

Student Birthdate

MM

DD

YYYY

Student Phone *

(###)

###

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Program Enrolling In *

Please select either 2 week program or 1 week options.

2-week program: June 15-26

1-week program: June 15-19

1-week program: June 22-26

Any Pointe Experience? *

Yes

No

Student Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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1. *

I understand that dance is a physical art form and injury is inherent. Every effort has been made to keep the studio a safe and appropriate environment for learning and performing dance class. If an injury does occur, the student is responsible for medical expenses incurred and will not hold Schramel Conservatory of Dance (SCOD) liable.

Yes, I understand.

2. *

I understand that the student may be touched appropriately by the teacher in order to achieve a certain position of the body as it pertains to the dance form.

Yes, I understand.

Date *

MM

DD

YYYY