Summer Camp Detailed Registration Form

Student Information

Student's Name *

First Name Last Name

Birth Date *

Month Day Year

Grade *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Cell Number *

Area Code Phone Number

E-mail *

Student's Shirt Size *

Parent/Guardian Information

Name *

First Name Last Name

Home Number *

Area Code Phone Number

Cell Number *

Area Code Phone Number

E-mail *

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Alt. Phone Number *

Area Code Phone Number

Does the Camper have any allergies, chronic illness, or medical conditions? If yes, please describe. *

Is the Camper prescribed an inhaler? If yes, please explain any instructions. *

Preferred Hospital *

Informed Consent and Acknowledgement: I hereby give my approval for my child’s participation in any and all activities prepared by Open Community Theatrer during the selected camp. In exchange for the acceptance of said child’s candidacy by Open Community Theatre, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Open Community Theatre, Academy of Creativity, or City Academy and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Open Community Theatre, Academy of Creativity, or City Academy. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all drama activities, including dancing, set building, and performances. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, loss of digits, or death. *

Yes No

Medical Release and Authorization: As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Open Community Theatre, Academy of Creativity, and/or City Academy, and its affiliates including Directors, Coaches, and Volunteer Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. *

Yes No

Media Release: I hereby grant permission for Open Community Theatre to take photographs of my child and use those photographs for electronic and print publicity including, but not limited to, production playbills photos, Facebook postings, and fliers. *

Yes No

Confirmation

BY ACKNOWLEDGING AND SUBMITTING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Choose one of these options *

3 week Improv Camp Mornings $ 200.00

Send me an invoice Free

Custom Camp (You Will Be Invoiced) Call Gaby at 801-433-7894 to arrange Free

OCT Improv Summer Camp