Mon Thurs 10Am 4Pm (Drop Off Option from 9Am Available)

The Starlight Company:

SUMMER HOLIDAY WORKSHOP 2017

EARLY BIRD REGISTRATION FORM

Monday 24th – Fri 28th July 2017

Mon – Thurs 10am – 4pm (Drop off option from 9am available)

Fri 430pm-830pm Performance to parents at 730pm

Please complete form and email to
& contact us for BACS details OR send form with

payment cash or cheques (made payable to The Starlight Company) to Rebecca White, The Starlight Company c/o 6 LITLEY CLOSE, HAMPTON PARK, HEREFORD, HR1 1TN.

RETURN BY 31STMAY

TO RECIEVE THE EARLY BIRD BOOKING RATE
SPLIT PAYMENTS CAN BE MADE AS LONG AS ALL MONEY RECEIVED
BY 30TH JUNE

EARLY BIRD OFFER: £70 10AM DROP £75 9AM DROP

AFTER 31ST MAY: £75 10AM £80 9AM DROP

INCLUDES TSHIRT & 2 TICKETS TO FRIDAY NIGHT SHOW
& DIGITAL PICS & VIDEO

SUMMER Workshop 10AM ( ) 9AM Drop off ( )

STUDENT DETAILS

Name ______

Age______TSHIRT SIZE (3-4,5-6,7-8,9-11,12-13,14-15)______

EMERGENCY CONTACT

Parent(s) or Guardian(s) Name(s)

Daytime Phone ______

Email Address ______

Does the student have or need assistance to participate due to a disability? NO ___ YES ___

If yes, please explain:______

Describe any other medical condition you feel we should be aware of (diet restrictions, asthma, etc.)______

DANCE HISTORY

Is this the student’s first year of dance? ______

Years of dance training completed ______

Former/current dance school(s) ______

How did you hear about us?

______

PHOTOGRAPHIC RELEASE

I agree that my child’s picture or likeness can be represented and published in any Starlight Company publication or local and national media.

Signature ______Date ______(If left blank we will not take a photo)

PAYMENTThere are no refunds given for any reason. I understand that if my child withdraws from the program during the workshop, that all fees and deposits are 100% non refundable. BACS, cash or cheques made payable to The Starlight Company.

Person responsible for payment (leave blank if the same as “contact 1” above)

______

Address: ______Phone ______

By signing this form, the parent/guardian is assuming any and all responsibility for the student, including financial obligations.

Signature ______

Date ______

DECLARATION

I (Parent/Guardian)name ______have enrolled (Student name)

______in a program of physical activity, offered by The Starlight Company. I hereby affirm that the above person is in good physical condition and does not suffer from any disability that would prevent or limit participation in this dance program. In consideration of myself, my heirs and assigns, hereby release The Starlight Dance Company, the owners Kim Owen, Rebecca White, Vicky Lightowler and Laura Lowe from any claims, demands, and causes of action arising from my or the above named person’s participation in any of the above stated programs, and I hereby release The Starlight Dance Company, the owners Kim Owen, Rebecca White, Laura Lowe and Vicky Lightowler, from any liability now or in the future including but not limited to heart attacks, muscle strains, pulls, tears, broken bones, shin splints, heat prostration, knee, lower back, or foot injuries and any other illness, soreness or injury however caused occurring before, during or after participation in any other of the above stated programs offered at The Starlight Dance Company or at any time, while in the vicinity of the premises of the above stated business, or in any activity sponsored, represented, or organized by The Starlight Dance Company, the owners Kim Owen, Rebecca White, Laura Lowe and Vicky Lightowler for any reason. By signing, I hereby affirm that I have read and fully understand and agree with the above waiver.

Signature of Parent/ Guardian ______

Date ______.

The Starlight Company

07912438309

Enrolment will not be completed until registration fee is received.

Thank you for registering for The Summer Workshop 2017 with
The Starlight Company