Fee $80
Bessie Smith Fall Break Dance Camp 2015
Date paid:_______________
REGISTRATION FORM
_____Cash _____Credit Card
_____ Check (Made payable to BSCC)
Camper’s Last Name:_______________________________ First Name:___________________________
Home Phone:____________________ Cell Phone:____________________ Birthdate:________________
Primary Email:____________________________________________ Age as of 10/5/15:_______________
Home Address:__________________________________________________________________________
City/State/Zip:___________________________________________________________________________
School:_______________________________________________________________ Grade:___________
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Parent/Legal Guardian:___________________________________________________________________
Address:_______________________________________________________________________________
Phone Numbers:_________________________________________________________________________
Health Insurance:__________________________________________ Policy #’s:_____________________
In case of an emergency, we will always attempt to notify the legal guardian first, but we would also like to
have another person to contact other than the parent or legal guardian in case they cannot be reached.
Emergency Contact:________________________________ Relationship:___________________________
Address:________________________________________________________________________________
Phone Numbers:__________________________________________________________________________
List anything the above camper is allergic to:___________________________________________________
Is there anything special we should know about this camper?______________________________________
_______________________________________________________________________________________
Liability Waiver: I understand and agree that in participating in any dance class, rehearsal or performance, there is the
possibility of physical injury. I agree, therefore, to assume all risks of any such injury to my minor child which might
occur during any and all Bessie Smith Fall Break Dance Camp events. I exempt, release and indemnify Bessie Smith
Cultural Center, its staff, guest artists and instructors from any and all liability claims, demands or causes of action
whatsoever from any damage, loss or injury to my minor child or my minor child’s personal property which may arise of
or in connection with participation in any classes or activities conducted by Bessie Smith Cultural Center, whether such
loss, damage or injury results from the negligence, passive or active of Bessie Smith Cultural Center, its staff, guest artists
or instructors from some other cause.
I have completely read and agree to the above Liability Waiver,
_________________________________
_________________________________
______________
Signature of Parent or Guardian
Print Name of Parent or Guardian
Date
Bessie Smith Cultural Center
200 E ML King Blvd Chattanooga, TN 37403
(423) 266-8658