Please provide the following contact information:

First Name
Middle Initial
Last Name
Home Phone
E-mail

Address

Street
City
State
Zip Code

Please identify and describe yourself:

Date of Birth
Age
Sex	Male Female
Dance Level	Beginner Intermediate Advanced
Home Phone#:
Day Phone #:
How did you hear about our camp?	E-mail Website Word of mouth Mail Out Other
If Other, Please specify where
t-shirt size	Child Small Child Medium Child Large Adult Small Adult Medium Adult Large Adult XLarge   T Shirt is free if you sign up by Nov 1st
Emergency Contact:
Relation:
Cell Phone #:
Method of Payment:	Cash Check Make check payable to Mandy Bell or Marcy Wuestenhoefer
Check #	$60.00 by Nov. 1st or $70.00 after Nov. 1st
Date:
Notes:

Agreement Waiver of Liability
As a parent or participant of Bodieography I know the risks and dangers of participation in such activities, and I am aware of the unexpected risks and dangers that may arise in participating in the above activity. In exchange  for permission granted to myself and/ or my child to enter and use the premises, I hereby, for myself, my children, my heir and assigns, and my child's heir's and assigns waiver and discharge Bodieography and all the employees, agents, facility, subcontractors, and successors in interest and Amanda Bell personally from all claims, actions, or cause of action for injury sustained to my or my childʼs person or the property regardless of the activity engaged. This waiver is operative regardless whether injury was caused negligence of any other fault. In the event that any portion of this agreement in declared void by a court of competent jurisdiction, the reminder shall have full force and effect. The release and waiver is to remain in effect. This release and waiver in to remain in effect for a period of three years from the date signed.