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Dance

CWU Dance team hosts Youth Clinic

Dance Clinic Sponsored by:
CWU Dance Team

Date:  Saturday  March 1st, 2014
Time:  2:30-3:00 pm  Registration
  3:00-7:30 pm  Clinic
  7:30pm  Performance at CWU Girls Basketball Game

  *Parents are allowed to watch kids perform for free but if they would like to watch
     the whole game they must purchase a ticket

Place: CWU Nicholson Pavilion Dance Studio

Cost:  $15.00 if registration is received by February 21st, 2014
(Includes Pom Poms)
  
$20.00 If registration is received after February 21st or if registering at the door (does not guarantee Pom Poms will be available the day of the clinic)

** Check or cash only no debit/credit
**Please make checks payable to CWU Dance
** Sorry, no refunds after February 21st

Ages: Kindergarten - 8th grade

Wear: Comfortable shorts/spandex/jazz pants, Central colored t-shirt (red, black, or white), sneakers or jazz shoes

Bring: Sack Lunch, Water Bottle

Learn: Dance basic fundamentals, leaps, turns and kicks.  A beginning, intermediate and advanced workshop will be offered, plus a routine to show parents at the end of the day.

Cut Here – Keep top portion for your records
** Please do not staple check to form **
Dance Clinic Registration Form (please print clearly)
Student Name:   Phone# 

Address:   Grade: 

City & Zip   School: 

Emergency Contact:   Phone: 

Email Address:    ________________________________________________________________________

Mail Registration Form To:
             Central Washington University PESPH Dance Program 
c/o Kayla Brown  
400 East University Way
Ellensburg, WA 98926-7572     
Questions? Call Kayla @ (206)947-4611

EMERGENCY/MEDICAL INFORMATION
           
Name_________________________         Date of Birth______________         Age: _______

PARENT/GUARDIAN INFORMATION
Address __________________________________________________________________
City ___________________________ State _______ Zip Code _________________
Mother/Guardian_____________________________ Day Phone _____________________
E-mail Address______________________________ Cell Phone _____________________
Campus Department (If applicable) _____________________  CWU ID#________________
Father/Guardian______________________________  Day Phone ____________________
E-mail Address______________________________  Cell Phone _____________________
Campus Department (If applicable) ________________________CWU ID#______________

OTHER EMERGENCY CONTACT INFORMATION (Other than Parent/Guardian)
Name_____________________________________  Phone_________________________
Relationship _______________________________ Alt. Phone ______________________
Name_____________________________________ Phone_________________________
Relationship _______________________________ Alt. Phone ______________________

AUTHORIZED INDIVIDUALS TO PICK UP CAMPER (BEFORE, DURING, OR AFTER CAMP)
(Please do Not List Parents/Guardians or emergency contact people)
Name_______________________________  Phone_________________________
Relationship _________________________  Alt. Phone ____________________
Name_______________________________  Phone_________________________
Relationship _________________________  Alt. Phone _____________________

CAMPER HEALTH PROFILE

Physician Name_________________________________ Phone ____________________
Medical Insurance Company & Policy Number _____________________________________
__________________________________________________________________________

MEDICAL HISTORY