Child’s Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Child 2 Name

First Name

Last Name

Child 2 Date of Birth

MM

DD

YYYY

Child's Name 3

First Name

Last Name

Child's 3 Date of birth

MM

DD

YYYY

Parent Name *

First Name

Last Name

Phone *

(###)

###

####

Phone 2

(###)

###

####

Emergency Contact Name

First Name

Last Name

What weeks will my child be in camp?

Please check all the weeks that your child will attend camp

July 29-August 2

August 5-9

August 12-16

Camp Hours: *

Monday-Friday 10:00 am – 2:00 pm *A minimum of 6 participants is needed to open a session. Full refund will be granted to all enrolled.

Venmo (@Lillian-Elbaz)

PayPal (@lillianelbaz)

Check (Made out to ‘Art of Movement’)

Cash

Credit Card ('Art of Movement website)

Other

Parent’s/Guardian’s Signature: *

By signing below, I give my child permission to participate in all camp activities. I hereby release and hold harmless the Art of Movement staff against all liabilities, and give permission to the staff to procure professional medical attention to my child in my absence. I understand that there is a weekly camp fee that must be paid before or on the Monday of the week of camp. I release of any liability in case of injury. I agree that Art of Movement staff take photographs of classes and performance for promotional purposes.

Signed by: *

First Name

Last Name