RDA Registration Form— Payment due w/ form.

Student’s Name____________________________

Age ______ Grade_____School_______________

(as of fall 07)

Dance Experience__________________________

Parent’s Name ____________________________

Address _________________________________

State ____ Zip ___________ Phone ___________

Emergency Contact ________________________

I certify that my son/daughter has no health or physical defect which will hamper his/her ability to participate in the RDA summer programs or be unsafe for his/her health. My son/daughter is covered by health insurance to cover any cost of accident and /or injury that may occur to him/her. Any costs not covered by insurance will be my responsibility. I waive RDA and its authorized agents or staff of all responsibility in the event of any type of injury, health condition, or physical problem that my son/daughter may already have or would incur during participation in the RDA programs.

Parent Signature _____________________ Date ________

Please register my child in:

___ Jam Session I ___ Jam Session II ___ Both

__ INTRO to Dance __ Hip Hop/Jazz Technique

__ Princess Camp— ___ JUNE ___ JULY

___ MUSIC VIDEO ___ JUNE ___ JULY

____ Ballet—JAM II only

__ Theater TROUPE JAM I only

___ Pointe Ballet (Thurs—June and July)

Total due _________ ___ Paid Ck # ___ Other ______

Rainbow Dance Academy

3925 Rainbow Drive

New Albany, IN 47150

812-948-9889

RDAstardancers@aol.com

www.WeCreateStars.com