Date __ Signature __

By c ompleting and signing this I give my consent to use of personal data.

mediterrane o DANCE festival 2012

First name ________________________________________ Last name________________________________________

in quality of group leader of the School / Group ____________________________________________________________

school address _______________________________________zip_________city__________________state__________

phones _________.____________________________ e-mail ________________________________________________

I request my self and all people of my group to participate in the activities of Mediterraneo Dance Festival 2012 that will take

place in Reggio Calabria, July 4 to 31.

On the arrival day I will present the membership request - self-declaration and release using image of myself and every

single member of the school - group, original receipt of payment cumulative payment and passport photos of

each participant.

1. Name _____________________________ Surname ______________________________ Deposit € ________

Courses ___________________________________________________________________________________

2. Name _____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

3. Name _____________________________ Surname _______________________________ Deposit € _______

Courses __________________________________________________________________________________

4. Name ____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

5. Name _____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

6. Name _____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

7. Name _____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

8. Name ____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

9. Name _____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

10. Name _____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

11. Name _____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

12. Name _____________________________ Surname _______________________________ Deposit € _______

Courses ___________________________________________________________________________________

N.B. for groups with more than # 12 components, please copy the model above and continue the list. Ability to

change courses within the first day of study.

- The group request to partecipate at the program of:

LAB 1 July 4 – 11 LAB 2 July 11 – 18

LAB 3 July 18 - 25 LAB 4 July 25 – 31

- Date of arrival day, place and time table

Дата добавления: 2015-11-14