Personal Information
Name (*)
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Address (*)
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City (*)
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Telephone (*)
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Email (*)
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DOB (*)
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In Case of an Emergency, Notify this Contact
Name (*)
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Relationship (*)
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Number (*)
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Immediate Medical Notifications (diabetes, required medications, and severe allergies ...INCLUDING FOOD, as luncheons and dinners are included):
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Additional Information
Are you representing a Pole Studio?
Yes No
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Studio Information
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Are you a pole instructor?
Yes No
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What Level do you fall under
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Basic Instructor Intermediate Instructor Advanced Instructor I am a Student Home (online, self) Class instructed
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What Level do you fall under
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Swings Only Basic Invert/Pose Split Grip Inverts Aerial Artistry
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How many years/months have you been pole dancing?
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Are you CPR/First Aid trained?
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Are you requiring accommodations?
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Fees and Accommodation Particulars:
Fee for 2012 Pole Camp is $350 CDN + 5% GST.
Please choose one
To provided email address, via Paypal, upon receipt of form. (+3% fee) To provided contact number, for payment via VISA/MC over telephone. To arrive in person at PoleJunkies for payment (local participants only).
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Because this event is international and required early deadlines, ALL Fees and Deposits are non-refundable. No cancellations, No Refunds, No Exceptions.
Bunk Buddy (Accommodation Sharing)
Please check here, if you are interested in sharing a room with someone to reduce costs. Your name/email will be added to the Bunk Buddy request list, and a mass email will be sent out to introduce you all to each other to arrange sharing. PoleJunkies is NOT responsible to ensure you have a buddy to bunk with…we just connect those who wish to share.
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General Information and Extras
Workshops, Private and Semi Private Classes will be available with Guest Instructors.
These workshops are ADDITIONAL to IPC Fees. Workshops are $60 + GST…..and
are on a First Book, First Served basis!
Registration DEADLINE is June 1, 2012 , and FINAL FEES
due June 15, 2012 to guarantee spot.
By completing and submitting this form, and attending the event, you hereby
agree and confirm that you are 18 years of age, and grant permission, which
permits all photo and/or video footage that is taken at IPC to be used in future
material by PoleJunkies and IPC. You also understand that all fees and deposits
are Non-Refundable after payment.
A $100
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