Sug +Bro
2015
Registration
2015
SEPTEMBER 4-6, 2015 • DOWNTOWN INDIANAPOLIS
Complete this registration form and submit the entire packet (including payment)
Mail to: Sugar & Bruno, 7260 Georgetown Road, Indianapolis, IN 46268
or Email to: [email protected]
ATTENDEE INFO
Attendee’s Name:
F
Gender:
M
Date of Birth:
Mini
Age:
Birthday during camp?
Junior
Teen
Y
N
Senior
Age 7-9
Age 10-12
Age 13-15
*Room ages subject to change due to class sizes. Dancer to be placed in ballroom based on age.
Age 16 & Older
Number of years dancing:
Do you dance with a studio?
Y
N
If so, please specify:
Y
Are you attending camp as a group from your studio?
N
CHOOSE ONE:
Crop Top
Shirt size:
Youth One Size
Crew Neck Tee
Shirt size:
XS
S
Adult S
M
L
XL
PAYMENT INFO
Registration includes: Entry to 10 classes, dinner on Friday, lunch on Saturday & Sunday, camper registration bag,
entry to the fun events and wifi access.
Earlybird Deal!
300
$
350
400
$
$
Registered and paid in full
by June 4, 2015
Registered and paid in full
June 5 - Aug 8, 2015
Registered and paid in full
Aug 9-Sept 4, 2015
OBS ERVER PA SS: $25
OBSERV ER PA SS: $ 40
OBSERV ER PA SS: $40
*Call for 2-day option and pricing
Make check or money order payable to:
Sugar and Bruno
Check #:
REGISTRATION:
$300 (paid by 6/4/15):
$350 (paid 6/5-8/8/15):
$400 (paid 8/9-9/4/15):
ADD-ONS:
$25 Observer (by 6/4):
Pay by credit card:
MasterCard
VISA
American Express
Account #:
Exp. Date:
Authorized Signature:
Scholarship Code:
Or Pay Online:
Visit www.sugarandbruno.com click the “Summer Camp” link
$40 Observer (6/5-9/4):
$50 Addl. Food Package (all 3 days):
TOTAL AMOUNT ENCLOSED:
$
Packet Page 1
Sug +Bro
2015
Registration
2015
SEPTEMBER 4-6, 2015 • DOWNTOWN INDIANAPOLIS
ACCOMMODATION INFO
Sugar and Bruno’s Dance Camp will be held at the beautiful Indianapolis Marriott Downtown
Indianapolis Marriott Downtown
350 West Maryland Street
Indianapolis, IN 46225
Phone: (317) 822-3500
The Marriott is offering an incredible reduced rate for all Sugar & Bruno camp
guests. Be sure to mention that you are with the Sugar & Bruno Dance Camp to
received the special rate, or if you would like to book your room online, go to
www.sugarandbruno.com and click on the “Summer Camp” link.
Will you be staying at the Marriott Hotel?
Y
N
(If yes, please fill in the information below. If no, continue to next section)
Name the room is booked under:
Number of rooms:
Dates of your stay:
Confirmation Number:
, 2015
Check-in:
, 2015
Check-out:
ATTENDEE HEALTH HISTORY (to be completed by a parent or legal guardian)
Attendee’s Name:
Parent/Guardian
E-mail Address:
Cell #
Home Address:
Work #
Home #
(Street)
(City)
(State)
(Zip Code)
Alternate Emergency Contact (Name/Relationship)
Cell #
Work #
Do you carry family medical/hospital insurance?
Carrier:
Home #
Y
N
If so, please indicate the following:
Policy or Group #:
1. Please list any health issues/conditions that your child experiences:
2. Please list current medication(s) your child is taking (Provide Instructions):
3. Please list any allergies your child experiences:
4. Any specific activities to be encouraged or limited by physician’s advice:
5. Specific needs (health, physical, or educational) for Sugar & Bruno staff awareness:
Packet Page 2
Sug +Bro
2015
Registration
2015
SEPTEMBER 4-6, 2015 • DOWNTOWN INDIANAPOLIS
PARTICIPATION AGREEMENT & WAIVER/RELEASE FORM
(initial)
(initial)
(initial)
(initial)
(initial)
PARENT AUTHORIZATION: I give permission for my child to participate in all camp activities. I understand that there
are potential risks associated with any program requiring physical activity, including this one. I hereby do declare
my child to be physically sound, having medical approval to participate in the activities of the Sugar & Bruno
Dance Camp. I understand and agree that Sugar & Bruno/PDA and the venue do not assume any financial
responsibility for medical expenses and/or compensation for any injury that my child may suffer during or resulting
from participation in this program or any other activities at the Sugar & Bruno Dance Camp location. I further
understand that neither Sugar & Bruno/PDA nor any of its paid staff, volunteer workers or venue staff can be held
responsible in the event of an accident. I certify that my child is amenable to discipline and free from habits or
attitudes, which would make him/her an undesirable participant.
EMERGENCY AUTHORIZATION: I authorize any representative of Sugar & Bruno/PDA to seek medical attention for
my child when immediate medical care is warranted by the circumstances and I cannot be reached, or if under
the circumstances there is no time to attempt to reach me because of the nature of the injury or illness. I further
authorize the health care professional selected by Sugar & Bruno/PDA to provide the necessary care and
treatment for my child.
PHOTOGRAPH/VIDEO AUTHORIZATION: Sugar & Bruno/PDA has my permission to use photographs/videos of my
child in Sugar & Bruno/PDA promotional material. I understand that I have no rights to the images produced and
therefore have no right to claim compensation for said images.
RELEASE AND WAIVER: In consideration of my child’s participation in the activities of the Sugar & Bruno Dance
Camp, I do hereby agree to hold free from any and all liability Sugar & Bruno/PDA and its respective officers,
employees and members and do hereby for myself, my heirs, executors and administrators, waive, release and
forever discharge any and all rights and claims for damages which I may have or which hereinafter accrue to me
arising out of or connected with my child’s participation in any of the activities of the Sugar & Bruno Dance Camp.
PICK-UP AUTHORIZATION: Please list in order of preference all persons who are authorized to pick up or be
responsible for your child. For your child’s safety, she/he will not be released to anyone else. Please include
yourself. Photo ID must be presented in order for camp to release an attendee.
Print Attendee’s Name:
Name
Signature
Relationship
Do not release my child to: 1.
Phone Number
2.
(initial)
OBSERVERS: I understand that observers will only be permitted into ballrooms if an observer wristband was purchased.
I also agree to act in a responsible and respectful manner if I am observing a class as a parent/guardian.
(initial)
REFUND: I understand that I will receive no refund under any circumstance that my child is unable to attend
camp. Please inquire with Camp Director for credit information.
(initial)
SIGNATURE: I certify that I am the parent or legal guardian of this child and that I have authority to make the
representations and grant the authorization contained herein.
CHILD’S NAME (Printed)
RELATIONSHIP TO CHILD
PARENT’S NAME (Printed)
DATE
Packet Page 3