2019 Summer Sampler Registration

Our Summer Sampler Sessions will be held on Wednesdays throughout the summer on the following dates: July 10, 17, 24, 31 / Aug 7, 14.

The Fundamental Sampler is for ages 3 – Kindergarten (must be 3 by 1/31/19). These classes will be from 5:45-6:30. The cost is $65.

The Elementary Sampler is for grades 1-4. These classes will be from 6:30-7:45. The cost is $85.

See complete Summer Sampler details.

Contact Information
Parent or Guardian Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Emergency Contact
Name*
First Last
Phone*
Relationship to Child(ren)*
Child Contact Information
How many children are enrolling?*
Child Name*
First Last
Child Birthday*
MM slash DD slash YYYY
Child Age (as of camp start date)*
Any health conditions/learning differences we should be aware of? If so, please explain.
Fundamental Sampler
Price:
Elementary Sampler
Price:
Child Name 2*
First Last
Child Birthday 2*
MM slash DD slash YYYY
Child Age 2 (as of camp start date)*
Any health conditions/learning differences we should be aware of? If so, please explain.
Fundamental Sampler
Price:
Elementary Sampler
Price:
Child Name 3*
First Last
Child Birthday 3*
MM slash DD slash YYYY
Child Age 3 (as of camp start date)*
Any health conditions/learning differences we should be aware of? If so, please explain.
Fundamental Sampler
Price:
Elementary Sampler
Price:
Child Name 4*
First Last
Child Birthday 4*
MM slash DD slash YYYY
Child Age 4 (as of camp start date)*
Any health conditions/learning differences we should be aware of? If so, please explain.
Fundamental Sampler
Price:
Elementary Sampler
Price:
Child Name 5*
First Last
Child Birthday 5*
MM slash DD slash YYYY
Child Age 5 (as of camp start date)*
Any health conditions/learning differences we should be aware of? If so, please explain.
Fundamental Sampler
Price:
Elementary Sampler
Price:
Account Agreement*
I agree to the privacy policy
I agree to abide by the policies and guidelines of KICKS Academy of Dance. I understand that there are no refunds, credits or deductions for classes missed or discontinued. On behalf of myself, my enrolled child(ren) and other family members in my care, I assume responsibility for any injury sustained or loss of property while on the premises of KICKS or any of its related events. I agree to hold harmless KICKS, its directors, instructors and any of its agents. I give permission for photos/video that include my child to be used for promotional purposes such as marketing or press releases.

Registration may be submitted at anytime. Full Payment is required with registration to secure your spot. Refunds will be granted if withdraw notice is submitted, in writing, by 6/15/19.

KICKS reserves the right to make schedule changes based on enrollment. In these unlikely situations, you would receive a full refund if no longer able to participate.
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Phone
This field is for validation purposes and should be left unchanged.

Contact Information

Emergency Contact

Child Contact Information