summer dance application 2012

JOSEPH’S DANCE STUDIO
Presents Ballroom & Latin Dance Camp
Oboz Tanca Towarzyskiego
At
SOYUZIVKA, Kerhonkson, NY
From August 19-August 25, 2012
SUMMER DANCE CAMP APPLICATION 2012
Student Name/
Imie i Nazwisko Ucznia:
(1)_________________________________________________
(2)_________________________________________________
(3)_________________________________________________
(4)_________________________________________________
Section where student dances/ _________________________________________________
Sekcja gdzie uczen tanczy
Address/ Adres:
___________________________________________________
__________________________________________________
E-mail
__________________________________________________
Telephone #/ telefon :_______________________________ ; ____________________________
Cell/kom; Work #/do pracy
Parents’ Name (if student is a minor)/
Imiona i Nazwisko Rodzicow
___________________________________________________
(jezeli student jest niepelnoletni)
______________________________________
Child’s Age/ D.O.B./
Wiek/ Data urodzenia:
(1) _______________________________________
(2) _______________________________________
(3) _______________________________________
(4) _______________________________________
Emergency Contact & Phone#/
Imie osoby i Numer telefonu
w naglych przypadkach :
________________________________________________
$200.00 deposit per student/ DEPOSIT IS NOT REFUNDABLE
Zaliczka $200.00 od osoby/ DEPOZTY NIE PODLEGA ZWROTOWI
Make check payable: Joseph’s Dance Studio
Parent’s or Guardian’s Signature /
Rodzice lub Opiekun Podpis:
___________________________________________