The Dance Academy of SC  come dance and spread your wings.

Puck’s Theatre:  changing the world through art.

 

 

 

Name (first, middle, last)

_________________________________________

Address

_________________________________________

Telephone (business) (home)

_________________________________________

Emergency Contact Phone

_________________________________________

E-mail

_________________________________________

Occupation

_________________________________________

Male / Female

I anticipate my desired level of technique to be:

1 = Beginning/Intermediate

2 =  Intermediate/ Advanced

Any chronic physical injuries? _________________________________________

Any special dietary considerations? _________________________________________

How did you hear about us? _________________________________________

Do you want us to connect you with a roommate? ________________________________________

f so, please answer the following:

Prefer a roommate in which age range? _________________________________________

Your Interests? _________________________________________

How can he or she contact you? ________________________________________

Waiver of Responsibility

I am aware that all forms of dance and the gymnastic exercises associated with it, place unusual stresses on the body and carry with them the risk of physical injury. I assume this risk and agree that the Dance Academy of S.C., its staff, and the facilities shall not be

 liable in any way for injuries sustained during attendance of the program or any of its

 functions.

_________________________________________________

Name

__________________________________________________

Signature                                                                   Date

 

Make checks payable to: Dance  Academy of South Carolina.

Send your application and check to:

Dance Academy of S.C.

212 West Carolina Avenue,

Hartsville, SC 29550.

A $150 cancellation fee will apply. No refunds within 30 days of the program. Credit cards are not accepted.

For additional information contact

Lesley Tunstall

at lesleyt@pivotalstage.com

or (843)861-0360.

 

 

Dance Academy of SC,

212 West Carolina Avenue,

Hartsville, SC 29550.

Visit our website at pivotalstage.com

Adult Dance Intensive 2005

Enrollment Application

July 11th–17th

Please print out form and mail in.