FALL DANCE CLINIC
SATURDAY,
September 29th
9:00 am - 1:30 pm
@ Manual Small Gymnasium
ü Kindergarten through 8th grade
ü Dancers will perform at Manual-Trinity Football Game
Oct. 5th @ 7:30 p.m.
ü ONLY $25 If
registration & payment received by September 28th !
ü Fee $30 at door. includes dance instruction, lunch, t-shirt
ü Checks payable to:
‘DAZZLERS BOOSTER CLUB
4807
Cedar Forest Place, Louisville, KY 40245
Dazzlers
2012 Fall Dance Clinic – ENTRY FORM
Dancers Name & Age_________________________________________________________________________
Parent or Guardian name _____________________________________________________________________
Address____________________________________________________________________________________
City________________________________ State_______ Zip_________ Email:__________________________
Emergency contact: __________________ Phone: ________________
Dazzlers 2012 Fall Dance Clinic – WAIVER FORM
Dancers
Name______________________________________
Please fill out each line completely with all
insurance information and signatures.
I, the undersigned
parent/guardian of the participant listed below, do hereby give permission for
him/her to atend and participate in the Manual Dazzlers Dance Clinic. I understand that by attending and
participating in this event, there is a possibility of physical illness or
injury to him/her. I hereby waive,
release and forever discharge any and all rights and claims for damages which
may arise against Jefferson County Public Schools, the Manual Dance Team, it’s
coaches, sponsors, and Manual Dance Team boosters. Furthermore, I authorize the directors of the
Manual Dance Team to act for me, according to their judgement in any emergency
requiring medical attention.
I certify that I have medical
insurance on my child that will provide coverage while he/she participates in
the 2012 Manual Dazzlers Fall Dance
Clinic.
Name of
participant__________________ Insurance Co Name___________ Policy
#______________
Group #____________
Parent Signature / Date________________________________
