EmailMe Form - Pajama Night Friday 2/8

Child *

First Last

Age/Grade

Primary Emergency Contact
(Parent/Guardian) *

First Last

Phone 1 *

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

Phone 2 *

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

Secondary Emergency Contact
(Parent/Guardian) *

First Last

Phone 1 *

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

Phone 2

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

Names of persons authorized to take child from the facility:

Name/s

Relationship

*Child will not be allowed to leave without authorization from parent

I understand that if I am late to pick up my child, my credit card on file will be charged $1/min. *

Yes

HEALTH INFORMATION

Permission Given to
Seek Medical Attention *

Yes

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

We provide one nut free snack. If your child has severe allergies we recommend you pack your own snack.

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
- diabetes, asthma, etc.
- NOTIFY 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

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.

Is there anything else we might need to know about your child?

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?

HELPS US HELP OTHERS FIND OUT ABOUT US

How did you find out about our camp?

Person completing this form *

First Last

Signature of parent/guardian who completed this form. You will next be directed to the payment site.

Clear

Use your mouse or touch pad to sign electronically