2015 Summer Dance Camps Registration Form Forms/payment may be sent to: Crossroads Irish Dance, LLC 730-B Research Road Richmond, VA 23236

Dancer’s Name____________________________ Age______ Date of Birth____________ Home Address______________________________ City______________ State___ Zip__________ Home Phone Number_______________________ Are there any known medical conditions that Crossroads staff and employees need to be aware? ___________________________________________________________________________________

Parents/ Guardian #1 _________________________________ Cell Phone: ______________________________ Email: __________________________________

Parent/Guardian # 2 __________________________________ Cell Phone: _____________________________ Email: _________________________________ Please select the camp (s) the dancer will be participating: Early Registration by July 31st ($5 off)   

Beginner Camp Teen/Adult Camp “Back To School” Intensive

August 11th & 12th August 17 & 18th August 19th & 20th

$60 $50 $50

$55 $45 $45

TOTAL AMOUNT DUE = __________________ Select Your Payment Method  Check - Payable to “Crossroads Irish Dance”  I would like to receive an electronic invoice to pay online via credit card or bank transfer I, the parent/ guardian of the above named dancer, hereby consent to the participation for the dancer in Crossroads Irish Dance, LLC for summer dance camp as selected above. I understand that payment for the selected camp above is due at time of registration in full and is nonrefundable. I am aware Irish dance is considered an intense sport and the rigorous exercises associated with it places unusual stresses on the body and carry with them the possible risk of physical injury. I declare that the above named dancer to be in good health and give permission for him/her to participate in any and all activities with Crossroads Irish Dance. I do not hold Crossroads Irish Dance, LLC or its employees liable for injuries that may occur during classes, rehearsal, dress rehearsals, performances, events, competitions given by Crossroads Irish Dance. I understand that photos and videos may be taken of my child/children/self throughout the dance year. By enrolling my child/children/self, I give my permission for such pictures/videos to be used for ads, social media, printed material or videos. A written authorization must be given by me, the parent/legal guardian, if I would like my child to opt out of being included in any pictures/videos, ads, social media, printed material or videos. Crossroads will use reasonable effects to not use any prior photographs which feature just your dancer, but will have the right to use any group photographs or videos that include your dancer. I give permission for a parent, chaperone or employee of Crossroads Irish Dance to seek medical attention for my child if necessary.

Parent/ Guardian Signature: __________________________________________Date: _______________ Dancer Signature (if 18 years or older) ___________________________________Date: _______________