Form

Student's Name:*

Date of Birth:*

- Month - Day Year

Address:*

City:*

State:*

Zip Code:*

Contact Number:*

E-mail Address:*

Please select:*

Youth (7-9) Intermediate (10-12) Advanced (13+)

Please make your selection:*

Winter Workshop: 1 Day $100.00 USD
Winter Workshop: 2 Days $200.00 USD
Winter Workshop: 3 Days $300.00 USD

Total: $0.00 USD

Please select the date/s you plan to attend our Summer Intensive:

Wednesday, December 28 Thursday, December 29 Friday, December 30

Release Form: By registering and clicking the submit button below it is confirmed that said person is aware of the nature of this event. Inaside Chicago Dance and faculty are not liable for personal injuries or loss of, or damage to personal property for any and all registrants. Each student may decline in participating in any activity. Please inform instructor of any physical limitation you may have. If you have doubt of physical limitations please consult with your physician before participating.

PLEASE NOTE:All purchases are non-refundable after December 19, 2011. Contact Inaside Chicago Dance for cancellation policy. All payments are processed through PayPal.

ONLINE REGISTRATION FORM