2019 2Dance4Life & Lakeland Academy Summer Camp Online Registration Form

Student First Name: *

Student Last Name: *

Street Address: *

City: *

Zip: *

Age: *

Male / Female *

Birthday: *

Email Address: *

Home Phone: *

Work Phone: *

Cell Phone: *

Grade: *

Current School: *

Parent / Guardian Names: *

Emergency Contact: *

Emergency Contact Phone: *

How did you hear about us? *

People that have permission to p/u child from camp: *

Allergies or Special Needs: *

Estimated Start Date: *

Please list any other special notes here such as special weeks attending