Louise Noel's Dance and Gymnastics, 87 Norman Street, West Springfield, MA - Phone: 413-736-5196

Student Name _____________________________________  Age _____  DOB ___________

Student Name _____________________________________  Age _____  DOB ___________

Camp Session ______________________  Full week/ 2 or 3 Day ______________ Before/ After Care ________

Street _____________________________________City ______________________State ____ Zip ___________       

Parent /Guardian Name: ____________________________________________ Home Pnone__________________

Emergency Contact _______________________________________________   Phone ____________________

Medical Limitations______________________________________________________________________________

Name of Health Ins _______________________________________________________________________________

Email Address __________________________________________________________________________________

How did you hear about LND&G ___________________________________________________________________

                      ($75 Deposit per session per child is returnable with a Dr. note) 


Louise Noel's Dance & Gymnastics, 87 Norman Street, West Springfield, MA 01089 • Phone: (413) 736-5196
Proud Member of: U.S. Gymnastics Association and National Association of Dance & Affiliated Artists
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Louise Noel's Dance and Gymnastics