2015 WHS Blackout Dance Team Clinic Registration Form

(For Grades K through 6th)

*Due to reduced seating in the HS Gym this year the Blackout Dance Clinic will be held during halftime of
a Home Varsity Basketball Game. We plan to return to Poms Night when the new gym is established!

Participants NAME(first & last)___________________________Grade____

Address: ___________________________________________________
City/Zip: _______________________________Phone: ______________
I give my child permission to participate in the Blackout Dance Team Clinic. All Williamsburg
Blackout dancers and coaches are hereby released from claim or liability for an accident or injury
occurring from the activity. Additionally I give permission to use photos taken during the clinic,
names will not be included.

Guardian Signature ___________________________________________

***EMERGENCY CONTACT & PHONE NUMBER DURING CLINIC***
Name:__________________________Number:_____________________
T-SHIRT SIZE:
(PLEASE CIRCLE ONE)

Child Small
Child Medium
Child Large

Adult Small
Adult Medium
Adult Large

(Detach here)

PLEASE ENCLOSE YOUR $20.00 CHECK (WITH CLINIC PARTICIPANT NAME

IN MEMO) AND THIS REGISTRATION FORM IN AN ENVELOPE AND RETURN TO
HOMEROOM TEACHER OR MAIL TO:

Melinda Gahring
PO Box 1009
Williamsburg, Iowa 52361

All checks payable: WHS Blackout

Due NO LATER than Monday, Jan. 19th!

If you have any clinic questions please call Melinda Gahring 319.530.8050
or email at melindasdancestudio@gmail.com. We look forward to a fun
clinic!
Clinic Date & Time:
Clinic Location:
Performance Date:

Includes:
Cost:
Registration Due:

Tuesday, February 10th 2015. From 3:35-5:30 pm

Williamsburg High School Cafeteria
Tuesday, February 10th @ Girls Varsity Basketball Game beginning at 7:30 pm
in Williamsburg High School Gym. Dancers need to meet in the High School
Cafeteria by 7:30 pm
Dance instruction from Blackout dance team, snacks & drinks, hair ribbon and
clinic t-shirt.
$20.00-Payable to WHS-Blackout (with participants name in the memo)
This fee is non-refundable.
No later than January 19th, 2015. (Along with payment)

*T-shirts and hair ribbon handed out at clinic.

Thank you for supporting the Williamsburg Blackout Dance Team!