Click Here to fill out the Required Health Form!
Please mail & make payments to:
KDC/Midwest Movement 2008
711 West 6th Ave., Emporia KS 66801
Name_________________________________________ Age_____
Address________________________________________
City__________________________________
State_________________ Zip______________
Parent/Guardian Name________________________________________
Phone( )____________________
Dormitory Mate Request__________________
Dance studio currently attending__________________________
Child Shirt Size (circle one): MD LG
Adult Shirt Size (circle one): SM MD LG
_____ I am enclosing the following $100 deposit before July 1, 2008. Balance
of $159.00 is due by July 15, 2008. DEPOSITS ARE NON-REFUNDABLE.
_____ I am charging my credit card the following $100.00 deposit on or before
July 1, 2008. Balance of $159.00 is due by July 15, 2008 (Provide Credit
Card Information Below).
_____ My registration is post-marked AFTER July 1, 2008. Enclosed please find
$275.00 in full.
_____ Day Student - $125.00, includes classes and t-shirt only.
_____________________exp._____________
Visa/Mastercard #
RELEASE: I agree that I will not hold Kari’s Dance Camp/Midwest Movement 2008 and staff of Emporia State liable for accidents or illness while attending the Dance Camp, nor will they be held responsible for loss or damage to personal property during the Dance Camp. I further agree to abide by the rules and regulations including the refund policy of Kari’s Dance Camp/Midwest Movement 2008, and agree to comply with them.
___________________________________________________
Signature of parent or guardian (under 18)
___________________________________________________
Camper’s Signature (over 18)