Performer Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

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I authorize Vox Artium to edit, copy, exhibit, distribute, and use any video or images taken of me during the Dance Clinic *

I agree

I understand that a cash payment of $20 is due the day of the clinic *

I agree

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

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