Cost- $35.00

1. 2013 Lil’ Bengals Dance Clinic and Performance Hosted by the ISU Bengal Dancers Cost- $35.00 Enjoy an all day experience taught by ISU Bengal Dancers. Clinic includes t-shirt, light snack, an autographed poster of the Bengal Dance team and FREE admission for performers at the Women’s Basketball game that afternoon (game starts @2:00). Discounted $2.00 tickets for family and friends at the ticket booth. When: January 26th, 2013 9:00-12:00 (Registration begins @ 8:30am) For girls & boys ages 4-12 Where: Reed Gym What to wear: Tennis/dance shoes, stretch pants/shorts/capris (color black preferred) NO SKIRTS PLEASE. Questions about registration: Call coach Kolissa Manchan at 208-282-4547 or email manckoli@isu.edumail registration to: ISU Bengal Dancers Kids Clinic Idaho State University STOP 8061 Pocatello, ID 83209-8061 ------------------------------------------------------------------------------------------------------------------------------------- Fill Out BOTH sides, Clip, and Return with check Payable to “ISU Bengal Dancers” Please pre-register by January 21st, 2013 to guarantee your child’s FREE T-shirt!!! Name:________________________________________________________Age:________________ Address:__________________________________________________________________________ City:_________________ Zip:_________ Ph#:____________________________ Email :___________________________________ T-shirt Size: Child Sm_____ Child Med_____Child Lg_____ Ad Sm _____Ad Med ______ Ad Lg_____ Total enclosed: $ __________ ($35/participant) check#_____ cash_____ TURN OVER TO FINISH SIGNING THE BACK OF FORM

2. PARENTAL CONSENT, RELEASE OF CLAIMS AND WAIVER OF LIABILITY FOR INJURY FROM PARTICIPATION IN IDAHO STATE UNIVERSITY’S BENGAL DANCERS LIL’ BENGALS KIDS CLINIC SATURDAY JAN 26th , 2013 I __________________ hereby grant permission for my child _________________ to participate in Idaho State University’s (ISU) Bengal Dancers lil Bengals kids clinic (BDLBKC) on Saturday Jan 26th, 2013. As Parent/Guardian, I understand and acknowledge inherent risks involved in this event, as well as risks caused from any third party unrelated to activity (past, present or future) and assume these risks and release ISU, its agents, employees, and officers from any liability for any and all personal injuries known or unknown, any injuries to property, loss, damage, expense, claim or cause of action, judgments and executions, including any reasonable attorney’s fees, that foresee ably arise from my child’s participation in ISU’s BDLBKC. I also grant consent for and release of photos/video of my child’s participation in ISU’s BDLBKC. I FURTHER STATE that I am of lawful age and legally competent to sign this affirmation and release; that I am responsible for my child’s welfare, and understand that this release legally binds me personally and releases me of my legal rights, and further understand the terms herein are contractual and are not a mere recital; and that I have signed this document as my own free act, As parent/ guardian of the above-named child, I hereby acknowledge and affirm the above-stated Release of Claims for my daughter/son having fully informed myself of the contents by reading it before I signed it. IN WITNESS WHEREOF, I have executed this affirmation and hereby release ISU on the day and year above written, on behalf of myself and any claim made by me on behalf of my child___________________________. Parent/Guardian Signature _________________________________________ Date __________________ Parent/Guardian (Print)_________________________Emergency Ph#_______________________________