Register Today! - Bessie Smith Cultural Center

Fee $80

Bessie Smith Fall Break Dance Camp 2015

Date paid:_______________

REGISTRATION FORM

_____Cash _____Credit Card _____ Check (Made payable to BSCC)

Camper’s Last Name:_______________________________ First Name:___________________________ Home Phone:____________________ Cell Phone:____________________ Birthdate:________________ Primary Email:____________________________________________ Age as of 10/5/15:_______________ Home Address:__________________________________________________________________________ City/State/Zip:___________________________________________________________________________ School:_______________________________________________________________ Grade:___________ ***********************************************************************************************************************

Parent/Legal Guardian:___________________________________________________________________ Address:_______________________________________________________________________________ Phone Numbers:_________________________________________________________________________ Health Insurance:__________________________________________ Policy #’s:_____________________ In case of an emergency, we will always attempt to notify the legal guardian first, but we would also like to have another person to contact other than the parent or legal guardian in case they cannot be reached.

Emergency Contact:________________________________ Relationship:___________________________ Address:________________________________________________________________________________ Phone Numbers:__________________________________________________________________________ List anything the above camper is allergic to:___________________________________________________ Is there anything special we should know about this camper?______________________________________ _______________________________________________________________________________________ Liability Waiver: I understand and agree that in participating in any dance class, rehearsal or performance, there is the possibility of physical injury. I agree, therefore, to assume all risks of any such injury to my minor child which might occur during any and all Bessie Smith Fall Break Dance Camp events. I exempt, release and indemnify Bessie Smith Cultural Center, its staff, guest artists and instructors from any and all liability claims, demands or causes of action whatsoever from any damage, loss or injury to my minor child or my minor child’s personal property which may arise of or in connection with participation in any classes or activities conducted by Bessie Smith Cultural Center, whether such loss, damage or injury results from the negligence, passive or active of Bessie Smith Cultural Center, its staff, guest artists or instructors from some other cause. I have completely read and agree to the above Liability Waiver, _________________________________

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Signature of Parent or Guardian

Print Name of Parent or Guardian

Date

Bessie Smith Cultural Center

200 E ML King Blvd Chattanooga, TN 37403

(423) 266-8658