Dance Camp of the Redwoods

Application Form

Please fill out, print and mail back this form to the address below.

Name:

Age:

Grade (fall):

Address:

Address2:

City:

State:

Zip:

Phone:

Email:

School:

I have studied (type of dance):
Number of years studied:
At (name of studio):
With (name of teacher):

Your Health Insurance Carrier:
Policy Number:
At (name of studio):
Name of Parent or Guardian:

Fee Enclosed*:

*Total fee $615; non-refundable deposit $100, balance due May 15th, 2004.

Note: A limited number of partial scholarships are available based on strong
dance committment and financial need. Please call Betsy Daley 510.841.0934
for more information.

I wish to have vegetarian meals.

Mail check and form to:
Dance Camp of the Redwoods
Betsy Daley
100 Delmar Avenue
Berkeley, CA 94708

I hereby absolve the Dance of the Redwoods staff from any liability which may
arise as the result of my child's participation in the above activity.

Signature of Parent or Guardian: __________________________________________

Date: ___________