REGISTRATION

Performer
Gender:  
First Name:   Last Name:    DOB:       
Address:  
City:   State/Region:   Zip/Postal Code:    
Email Address:
*all correspondence for the event will be sent to this email address     Phone:  
Studio:   Teacher:  
What email do you have associated with your dance bug account?
Headshot:
 
Location & Package Options
Location:  
Qualified at:
Referred By:
Will the participant be performing in the Improv Showcase? ($30.00)?

 
Would you like to add the NEXT STEP Package? ($70.00)?

 
Would you like to add a Power Pak Jacket? ($60.00)

 
Apparel Size
Street Shoe Size:    
T-Shirt Size    
Hotel or Commuter Package
 
Chaperone / Guests

OPTION 1

Are you registering as official chaperone / guest for this performer?
If yes, click add chaperone / guest.
You will need to click add chapreone / guest for each chapreone / guest attending with this performer.  
*Every Performer is required to attend Power Pak with a registered chaperone / guest.

OPTION 2

Is this performer attending Power Pak with a chaperone / guest who is registered, as official chapreone / guest, with another performer?

Enter Performer Name
Package Summary
Item Description Price Quantity Amount
Performer Package $900.00 1 $900.00
Total $900.00
Scholarships & Discounts
Only 1 scholarship may be redeemed per dancer.
After submitting your registration, please submit proof of scholarship to [email protected].
Scholarship:
Payments
Payment

Billing / Credit Card Details
First Name:   Last Name:  
Address:  
City:      State:   Zip:    
Card Number:     Exp Date:        CVV:  
Current Balance:
Charge Amount: * $75 deposit is required to register.        
Emergency Contact
* All fields in this section are required

Parent/Guardian
Name:  
Work Phone:  
Cell Phone:  

Alternate Contact
Name:  
Relationship:  
Work Phone:  
Cell Phone:  

Family Physician
Name:  
Phone:  
Dismissal Info (Optional)
Please complete the following dismissal release information if you know an adult over 21 years of age who is registered as a Power Pak chaperone / guest that you would like to give permission for your child to go with during Power Pak free times. Performers will only be released to their parent or guardian if this section of the form is not completed. Power Pak reserves the right to revoke permission if there is any violation of the Power Pak rules set forth for the tour.

I hereby grant permission for the chaperone(s) / guest(s) listed below, who are a part of the Power Pak tour, to pick up/drop off and supervise my child during Power Pak free times. I understand that the chaperone(s) / guest(s) must be a part of the Power Pak tour and must be over 21 years of age.
Chaperone / Guest #1: #2: #3: #4:
Parent/Guardian Signature:
Senior Dismissal Info (Optional):
This section must be completed if your child is 13 or older, traveling with their parent or guardian, and wishes to have permission to be dismissed from Power Pak activities without a parent or guardian present. If this section is not complete, Performers will not be dismissed until a parent, guardian or chaperone / guest listed above is present at dismissal.

I hereby grant my permission for my child to be dismissed without a parent, guardian or chaperone / guest present. I understand that Power Pak reserves the right to request a chaperone / guest be present at dismissal from specific activities if they feel necessary.

Parent/Guardian Authorization:
Signature Authorization

I,   , Parent or Guardian of the performer listed above, have read and agree to the following Power Pak Documents:

Power Pak Documents and Policies

By clicking the submit button below I acknowledge that I understand and agree to all of the terms stated
in the above listed Power Pak Documents.

*** ATTENTION: Clicking the submit button multiple times could result in multiple charges! ***