SUMMER THEATER PERFORMING ARTS CAMP 2012

Sewickley Academy, 315 Academy Avenue

Sewickley, PA 15143 412-741-2230

http://www.performingartscamp.net

REGISTRATION FORM

Program of Interest – Check One: (see the General Information page for help)

Group I $775_____ Group II $775_____ Group III $775_____ Group IV $775_____

Group V $775____ Combined Groups III & V $825_____ Combined Groups IV & V $825______

Student’s Name____________________________________Male__________Female__________

Date of Birth__________________________Age_______Grade Completed ’11 -‘12____________

Parents’ Names____________________________________________________________________

Address_________________________________City__________________State______Zip________

Parent e-mail that’s checked EVERY DAY________________________________________________

Phone: Home__________________________

Dad’s Work/cell (circle one)_________________Mom’s Work/cell (circle one)__________________

*********************************************************************************************************************

Emergency Contact Person_____________________________Relationship____________________

Telephone_______________________________

*********************************************************************************************************************

Student’s e-mail____________________________Student’s Present School____________________

Student’s Previous Training/Experience_________________________________________________

Student’s t-shirt size: Youth Size: M____L____ Adult Size: S____M____L____XL_____XXL_____

“I understand the rules governing tuition and conduct at camp and agree to abide by them.

I further agree to release Summer Theater Performing Arts Camp, its owners, operators, and other employees from any claims which may arise due to the use of school and camp facilities and/or the student’s physical condition.”

Parent/Guardian Signature____________________________________Date________________

***DEPOSIT OF $350 IS DUE BY JUNE 2 WITH THIS REGISTRATION FORM***

Please make check payable to: PAC 2012

******************

MEDICAL EMERGENCY INFORMATION

If a parent/guardian cannot be reached at once in case of accident or illness at camp requiring immediate medical attention, I give my permission for the camp to summon emergency medical services and to obtain necessary emergency hospital treatment.

YES or NO(circle one) ______ Signature____________________________________________

Insurance Carrier Name and Group/Agreement # ________________________________________

Permission to give JR. STRENGTH TYLENOL (Ages 6-12) or ADVIL (Aged 12+) (YES or NO)_____

Please inform us of allergies or any condition we should know about during this camp.