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(For Grades K through 6th)
Detach & mail top of page only. Please keep bottom of the page for you to refer to.
Participant’s NAME(first & last)___________________________Grade____ Address: ___________________________________________________ City/Zip: _______________________________Phone: ______________
I give my child permission to participate in the Blackout Dance Team Clinic. All Williamsburg Blackout dancers and coaches are hereby released from claim or liability for an accident or injury occurring from the activity. Additionally I give permission to use photos taken during the clinic, names will not be included.
Guardian Signature ___________________________________________ ***EMERGENCY CONTACT & PHONE NUMBER DURING CLINIC*** Name:__________________________Number:_____________________
(PLEASE CIRCLE ONE)
Child Small Child Medium Child Large
Adult Small Adult Medium Adult Large
PLEASE ENCLOSE YOUR $20.00 CHECK (WITH CLINIC PARTICIPANT NAME
IN MEMO) AND THIS REGISTRATION FORM IN AN ENVELOPE AND RETURN TO HOMEROOM TEACHER OR MAIL TO:
Melinda Gahring PO Box 1009 Williamsburg, Iowa 52361
All checks payable: WHS Blackout Due NO LATER than Friday, Jan. 17th!
If you have any clinic questions please call Melinda Gahring 319.530.8050 or email at firstname.lastname@example.org. We look forward to a fun clinic!
Clinic Date & Time: Clinic Location: Performance Date: Includes: Cost: Registration Due: Saturday, February 8th 2014. From 10am-12pm Williamsburg High School Gymnasium Saturday, February 8th @ Poms Night beginning at 7 pm in Williamsburg High School Gym. Dancers need to meet in the Multipurpose Room by 6:15 pm. Dance instruction from Blackout dance team, snacks & drinks, hair ribbon and clinic t-shirt. $20.00-Payable to WHS-Blackout (with participant’s name in the memo) This fee is non-refundable. No later than January 17th, 2014. (Along with payment)
*T-shirts and hair ribbon handed out at clinic. Thank you for supporting the Williamsburg Blackout Dance Team!