summer dance application 2012
Transkrypt
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: ___________________________________________