EmailMe Form - 2016 Summer Little Theater Form (Laf)

Which week are you attending? *
Student *
First Last
Primary Emergency Contact
(Parent/Guardian) *
First Last
Phone 1 *
### - ### - ####
Phone 2 *
### - ### - ####
Secondary Emergency Contact *
First Last
Phone 1 *
### - ### - ####
Phone 2
### - ### - ####
HEALTH INFORMATION
Permission to Seek Medical Attention *
Yes
Checking "Yes" authorizes Kids 'N Dance 'N Theater Arts to seek emergency medical attention for the above named camper.As the parent or authorized representative, I hereby give consent to Kids N Dance N Theater Arts to obtain Medical or Dental care prescribed by a duly licensed physician (MD) or dentist (DDS). This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of the child named above.
I am aware that families are asked to pack lunches and snacks free of peanuts and tree nuts including those that may have traces of nuts. *
Yes
If campers inadvertently bring nut products to camp, they will be asked to eat one of our nut free snacks instead. We apologize for the inconvenience and appreciate your support in helping create a safe environment for all campers. If your child has a nut allergy, it is still important that you notify staff and inform us whether an epi pen is to be supplied.
List any pertinent health concerns:

-allergies
-medication
-special needs
- PLEASE INFORM OF EPI PEN NEEDS
All medications must be provided to the staff and administering directions must be detailed here PLEASE CONFIRM NOTIFICATION AT SIGN IN
Is there anything else we might need to know about your child?

-social / emotional needs
We want your child to have the best possible experience. Is there anything we should know about your child that will help us know what their needs are?
ARE YOU REGISTERED FOR BOTH MORNING AND AFTERNOON CAMPS?
Is your child registered for both camps requiring supervision from 1:00-1:30? *
Yes
No
If yes, make sure to pack an extra snack.
PICK UP

Campers can be picked up in the 15 minute window BEFORE camp ends. We appreciate you making every effort to pick up your child on time because teachers have other responsibilities after camp. Charges of $1/minute will accrue after the 15 minute window of time to pick-up campers.
I understand that if I am late to pick up my child, my credit card on file will be charged $1/min *
Yes
SOME LOGISTICS
Publicity *
Yes
Checking "Yes" indicates you agree to the following: I grant Kids ‘N Dance / Onstage representatives and employees the right to photograph or digitally record rehearsals or shows and authorize them to copyright, use and publish them.
Release of Liability *
Yes
Checking "Yes" indicates you agree to the following: I voluntarily enroll my child with full knowledge that there is risk of personal injury in any activity affiliated with KND. I agree neither I, my heirs, assigns or legal representatives will sue or make any other claims against Kids N Dance/Onstage, its members or employees for any degree of personal injury, property damage/loss, regardless of cause.
HELPS US HELP OTHERS FIND OUT ABOUT US
How did you find out about our program?
*
Kids 'N Dance Fan
Facebook Advertisement
Email Newsletter via Kids 'N Dance
On-line Camp Listing
General Internet Search
Friend
Other (please specify)
Person completing this form *
First Last
Signature of parent/guardian who completed this form *
Clear
Use your mouse or touch pad to record an electronic signature

HEALTH INFORMATION

ARE YOU REGISTERED FOR BOTH MORNING AND AFTERNOON CAMPS?

PICK UP

SOME LOGISTICS

HELPS US HELP OTHERS FIND OUT ABOUT US