EmailMe Form - Broadway Bound Summer Camp Registration Form

Student Name: *

First Last

Date of Birth: *

MM / DD / YYYY

Age: *

All students must be between 7 and 18

Student is entering which grade in the fall?:

School (optional, we like to ask for marketing and community development purposes):

Student's T-Shirt Size: *

Parental Guardian Information

The following questions are in regard to the parental guardian(s) of the student.

Primary Parental Guardian Name: *

First Last

Secondary Parental Guardian Name (optional):

First Last

Primary Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Primary Phone: *

### - ### - ####

Secondary Phone:

### - ### - ####

Parental Guardian's Email: *

On Wednesday, 8/12, students will get to see our professional production of HAIRSPRAY! The show is from 2 - 4:30 PM, so please note that pick-up on Wednesday will be at 4:30, not 3:00. Students of our camp will see the show for free, however, If you would like to join us for this production, we can put a ticket aside for you and up to one other guest at a discounted price of $35 (regular adult tickets are $50). Please let us know below if you would like to take advantage of this discount and join us Wednesday afternoon. If you do, we will set your ticket up and send you a link to pay separately prior to the show. *

Yes, please save me 1 ticket at $35.

Yes, please save me 2 tickets at $35 each.

No, thank you.

Please note tickets must be paid for before the Wednesday performance and are non-refundable. This discount is only valid for the 8/12 afternoon performance and in conjunction with Broadway Bound. Only 2 discounted tickets available per family, if you would like to purchase more tickets at the regular price, please let us know and we will be happy to assist you.

Student Medical Questions

Please answer the following questions with any information you think might be important or helpful for us to know while caring for the student during classes.

Please List any allergies, disabilities, or other illnesses that may affect participation:

Please list any medications that need to be monitored while the student is at camp:

Is there anything else you'd like us to know?:

Emergency Contact Name: *

Please list a person who is NOT a parental guardian. We will only contact this person if we cannot reach a parental guardian using the contact information previously given.

Emergency Contact Relation *

Emergency Contact Phone *

### - ### - ####

I give permission for my child to be transported to an area hospital; and should my child be taken to the hospital for emergency purposes, I hereby give permission to the attending physician and staff to treat my child with anesthetic, medical, x-ray, and surgical procedures as may be deemed necessary or advisable by a medical professional. I understand that in an emergency, NCCA Jean's Playhouse will make every attempt to communicate with me prior to use of this waiver. *

I agree

I give permission for NCCA Jean's Playhouse to take and use photographs and audio/video recordings of my child and family during their time at the camp and showcase. The use of these photos/recordings is limited to marketing and advertising purposes using media such as, but not limited to, the company website, social media, print ads, email blasts, newsletters, and the like. *

I agree

Signature *

Clear

Today's Date: *

MM / DD / YYYY

Thank You!

Please select SUBMIT and you will be forwarded to our payment portal so you can make the tuition payment. PLEASE NOTE YOUR SLOT WILL NOT BE HELD UNTIL A PAYMENT IS MADE.