EmailMe Form - 2016 Summer Dance or Circus Arts Camp Form (Oak)

Which camp 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

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

Additional Persons that may be called in an emergency:

Name
Phone
Relationsihp

Names of Persons Authorized to take child from the facility:

Name/s

Relationsihp

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

PICK UP INFORMATION
Dance Camp ends at 12:00
Circus Camp Ends at 4:00

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. Extended care must be arranged 24 hrs in advance to avoid the late pick up charges.

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

Yes

EXTENDED CARE

- Registration required 24 hours in advance. Staffing may not otherwise be available.
- Register on-line, by calling, or in person
- $10/hr (8:30-9:00/12:00-1:00/4:00-5:00/5:00-6:00)
- Reservations are in one hour increments with the exception of early care
- No refunds

I need extended care *

Yes

No

I believe I have already paid and registered for extended care *

Does Not Apply

Yes, I have already registered for extended care

No. I have not YET registered, but I understand that I must pre-register a FULL 24 HOURS NOTICE IN ADVANCE

HEALTH INFORMATION

List any pertinent health concerns:
- allergies
- medication
- diabetes, asthma, etc.
- PLEASE INFORM IF EPI PEN IS NEEDED

All medications must be provided to the staff and administering directions must be detailed here PLEASE CONFIRM NOTIFICATION AT SIGN IN

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

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.

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 during class. 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 *

Clear

Use your mouse or touchpad to sign electronically.

PICK UP INFORMATION Dance Camp ends at 12:00 Circus Camp Ends at 4:00

EXTENDED CARE

HEALTH INFORMATION

SOME LOGISTICS

HELPS US HELP OTHERS FIND OUT ABOUT US

PICK UP INFORMATION
Dance Camp ends at 12:00
Circus Camp Ends at 4:00