QCPA 2023 Summer Dance Intensive Question Title * 1. Student's Name Question Title * 2. Date of Birth DOB Date Question Title * 3. Parent Name Question Title * 4. Primary Contact Number Question Title * 5. Email Address Question Title * 6. Desired Payment Option Weekly payments of $250 beginning 7/3/23 Monthly Payment Plan 50% down, 50% due on 7/3/23 Question Title * 7. Emergency Contact- Name, Relationship, and Phone Number Question Title * 8. Allergies or Medical Conditions (If medication is needed, please provide medication information) Question Title * 9. T-Shirt Size Child XS Child S Child M Child L Child XL Adult S Adult M Adult L Adult XL Question Title * 10. Dance Experience Done