Hosted by: Mrs. Heidi & CHS Jazz

 Hosted by: Mrs. Heidi & CHS Jazz
Monday, June 22nd – Wednesday, June 24th
8:30 a.m. – 5:00 p.m.
Catholic High School Cafeteria
Ages Pre-K – 8th Grade
Participant Name: ________________________________________________________ Age: _________ Grade: _________ Mailing Address: ______________________________________________________________________________________ City: __________________________________________________________ State:_______ Zip Code: _________________ Parent/Guardian Names: _______________________________________________________________________________ Home Phone: ( )_______________ Cell Phone: ( ) ____________________ Parent/Guardian Email :_________________________________________________________________________________ Emergency Contact (other than parent) ___________________________________Phone: __________________________ Please list any medical conditions we should be aware of: ____________________________________________________ ____________________________________________________________________________________________________ I hereby request my daughter be admitted to the CHS Jazz Dance Clinic and authorize the camp director to act for me to her best judgment in any emergency requiring medical attention for which I shall pay. _______________________________________________ (parent/guardian signature) Pizza and hamburgers will be sold for
lunch. Snacks and drinks will also be sold.
For more information,
contact Heidi Dueitt at
hdueitt@chspanthers.com.
Pre-­‐registration ends Monday, June 15th. th
Anyone registering after June 15 will NOT receive a T-­‐shirt. $__________ Clinic Fee $120 Make checks payable to: Catholic High School Please return to: Catholic High School C/O Heidi Dueitt or mail to 2801 Captain Cade Road Broussard, LA 70518 Please Circle T-­‐shirt Size: Youth: XS S M Adult: S M L L XL