AGES: 9-12 (Cannot attend after turning 13)
Cost: $3.00 per dance
Time: 7:00 p.m. - 10:00 p.m.
Date: (one dance each month - Sept - June)

NOTE: If possible, we would request that one parent from each family volunteer at one of the ten dances
             held throught the year. Without volunteers, we can not keep these dances running.

Parent or Guardian Name:   ___________________________________________________

       Home Phone No:  ____________________________________________________________

Childs Information:

Last Name: __________________________________________________________________

First Name: __________________________________________________________________

Date of Birth:  Day ______________ Month _________________ Year ________________

Home Address: ______________________________________________________________

            Emergency Contact Name(s) #1: _____________________________________________________

Emergency Contact Phone #1: _________________________________________________

Emergency Contact Name(s) #2: ________________________________________________

Emergency Contact Phone #2: _________________________________________________

Family Doctor: _______________________________________________________________

Family Medical #: ____________________________________________________________

Personal Medical Identification #: ______________________________________________

List any medical condition we may need to know about: __________________________

____________________________________________________________________________

The medical information is necessary in case of illness or injury. All information will be kept confidential. 

The Westdale Community Centre is not responsible for any lost or stolen items.  Children are not allowed to leave the

building unless they are going home. Those who leave the building are not allowed back in as the doors are locked.

Parent's Signature: ____________________________________________________________