Summer Camp - Official Flyer

A Wonderful & Creative Experience

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Art in a Box Co.

Summer Registration Form 2014

 

Workshop Name: ____________________________Week:____________________Total Fee:$ ______

                                    Early Registration:  Y / N    Sibling Discount: Y /N    Deposit: Y / N

Name:_______________________________________________________________________________

Address:_____________________________________________________________________________

Date of Birth: ____________Age:____________  M / F    Grade:______ School:____________________

Sibling(s)_______________________________________

Contact Information

1.Parent/Guardian  Name: __________________________Home#_______________Cell#___________

2.Parent/Guardian Name:___________________________Home#_______________Cell#___________

Emergency Contact(if different from above)________________________________________________

 

Medical Information

Name of Doctor: ______________________ Location:________________________Tel#_________________________

Name of Dentist:______________________Location:_________________________Tel#________________________

Allergies:________________________________________________________________________________________

Medication:______________________________________________________________________________________

Pick-Up Information: If assigned pick-up person is different than parent, please provide their information. 

           Also, please provide a note for day(s) of pick-up.

Name:__________________________________ Relation:___________________ Contact #:_____________________

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I give my child,______________________, permission to participate in the summer camp at Art in a Box Co. I agree to comply with all program rules and hereby indemnify and hold harmless the staff, management, and visiting specialist(s) from any and all liability for injuries incurred at the camp or off-site locations affiliated with camp.

Parent Name: print______________________Parentsignature__________________________Date:______