¨  COMBO: Triple Threat Session #2 + Dance Intensive  Fee:  $850.00        ¨  COMBO: Triple Threat BOTH Sessions #1 & 2 + Dance Intensive  Fee:  $1200.00

PAYMENT: (Full payment payable to Randolph Academy)  * Registrations will not be accepted without full payment.  Post-dated cheques not accepted.

__ Cheque     __ Money Order     __ Cash     __Debit    __ Visa     __ M/C    # _______________________________________  Exp. Date: _______

Name on Visa or M/C:  __________________________________________________    Signature:  _______________________________________________

Refund Policy:  Prior to June 15, 2010 - Full refund less $50 administration fee.  After June 15, 2010 - No refunds will be issued.  All withdrawals must be done in writing.

Randolph Academy for the Performing Arts

NAME OF STUDENT  ____________________________________________________________________________________________________

EMERGENCY CONTACT:       Name: __________________________________________    Phone Number:  ____________________________

CONFIDENTIAL MEDICAL INFORMATION FORM (In order for us to provide the best camp experience possible for your child, we ask that you answer the following questions as candidly and honestly as possible).

Has your child ever suffered from asthma, heart problems, breathing problems or any other medical condition that may affect his/her ability to participate in this program?

__________________________________________________________________________________________________________________________________

Is your child on any medication?   ______________________________________________________________________________________________________

Has your child ever been diagnosed with any psychological and/or behavioral problems?

___________________________________________________________________________________________________________________________________

Does your child have any allergies?  Please specify.  _______________________________________________________________________________________

INJURY WAIVER AND PHOTOGRAPHY AND VIDEO WAIVER

The undersigned understands that there is a certain element of danger in dancing activities and acknowledges that it has been explained to her/him that caution and care reduce the element of danger and injury.  The undersigned also understands and agrees that the school reserves the right, at any time, to void this membership for an action by the member that the school deems undesirable.  The undersigned represents that he/she is physically sound and has medical approval to proceed with normal routine exercise applicable to the dance arts.  I hereby grant permission for my child to participate in all RANDOLPH ACADEMY program activities including photographs and recordings and allow the use of any such material in which my child appears, for promotional, instructional, educational or commercial purposes.  I hereby release RANDOLPH ACADEMY and its staff members from all claims for damages arising from participation by my child, during any program or in any facility or any location where a program is held.  I hereby give permission to have staff arrange for emergency medical care including transportation if necessary.

Signature of Parent/Guardian: ___________________________________________________________     Date: _______________________________________

PLEASE NOTE:  No campber will be considered registered unless ALL waivers are signed.  REGISTRATIONS WILL NOT BE ACCEPTED OVER THE TELEPHONE.

Please send fully completed application form and payment to:  Randolph Academy for the Performing Arts (Attention: Nicole Sloan)

736 Bathurst Street, Toronto, ON     M5S 2R4

Fax: 416-924-1535      Phone: 416-924-2243 x225      kids@randolphacademy.com