Student's Name __________________________________________________________________
Last First MI
Address ___________________ City _____________ State ____
Zip Code _____
Date of Birth: ___________ Male / Female Grade _______ Age ________
Parent/Guardian/Name ________________________Phone ______________
email: _______________________________ Cell _______________________
Emergency Contact: Name _______________________
1) The students will receive instruction, guidance, and encouragement.
2) The sponsor (A Cinderella's Dream-Camp/Class Director) reserves the right to
dismiss any student whose conduct proves not to be in harmony with the camps'
3) A Cinderella's Dream reserves the right to cancel or alter any scheduled course if
necessary. If a course is canceled, camp, class or workshop fees will be refunded.
4) I understand that no camp, class or workshop fees will be refunded once class starts.
If you cancel a class, we will reschedule your time.
5) A non-refundable fee of $25.00 is required to reserve your space.
The balance of camp, class or workshop will be due on or before the first day of instruction.
Parent/Guardian/Self Signature ________________________
Medical Release & Waiver Agreement
I agree to release and hold harmless A Cinderella's Dream, and it's instructor's from any
and all losses, liabilities, claims, and expenses that may occur as a result of my child/myself
participation in any camp, class or workshops.
Emergency Name and Phone #: _________________________________________
Physician's Name: ___________________________
Phone #: _________________
Special Needs: _______________________________________________________
Known Allergies: _____________________________________________________
Current Medications: ___________________________________________________
In the event of an accident or injury to my child, I hereby give my consent for
A Cinderella's Dream director and staff to arrange medical treatment for my child/myself
in the event I cannot be reached. I understand that I will be financially responsible for any
medical treatment or service given to my child/myself.
Parent/Guardian Signature: _________________________
I give A Cinderella's Dream permission to use photos taken of my child/myself during camp,
or class for publication of its website and or for advertisement purposes only. ___Yes ___ No
We will not use any names.
Parent/Guardian Signature: __________________________ Date: _________
Cost: __________ Payment: __________ Balance Due: __________ Check # ___________
Please copy and mail in to: A Cinderella's Dream. P.O. Box 924912 * Houston, Texas 77292-4912.