Arlington County-Registration Form

ARLINGTON COUNTY SUMMER CAMPS

REGISTRATION FORM

1. General Information

NOTE: PLEASE FILL OUT A SEPARATE FORM FOR EACH CHILD

* Indicates required field

Child's Name *

First

Last

Select One *

Age *

Child's Birthdate (mm/dd/yyyy) *

Parent/Guardian Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Type of Camp *

Act it Out! (4-6)-Madison CC-Aug 1-5-$185.00 Act it Out! (4-6)-Ashlawn ES-Aug 15-19-$185.00 Dramatic Kids! (6-11)-Ashlawn ES-July 25-29-$295.00 Dramatic Kids! (6-11)-Ashlawn ES-Aug 15-19-$295.00 Theatrical Teens! (11-15)-Ashlawn ES-Aug 15-19-$295.00 Theatrical Teens! (11-15)-Ashlawn ES-Aug 22-26-$295.00

Name of Person Picking up Child from Camp *

Relationship to the Child *

2. Medical & Emergency Contact Information

Allergies (if applicable) *

Primary Emergency Contact *

Primary Emergency Contact Phone Number *

Secondary Emergency Contact *

Secondary Emergency Contact Phone Number *

Please list any special assistance or accomodations needed *

3. Photo Release Agreement

I grant to C.A.R.E. Actor LLC the right to use photographs of my son/daughter and my family in connection with the above-identified event. I authorize C.A.R.E. Actor LLC to use these photographs in promotional materials i.e. brochures, website, marketing materials for such purposes as publicity, illustration, advertising, and web content.

Select One *

4. Hold Harmless Agreement

As the legal parent or guardian, I release and hold harmless C.A.R.E Actor LLC, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of C.A.R.E Actor LLC its owners and operators or enroute to or from any of said premises.

Hold Harmless Agreement *

I've read the above and agree.

Additional Comments *

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SUBMIT FORM

**PLEASE SUBMIT YOUR INFORMATION AND THEN PURCHASE A CAMP PACKAGE ON THE NEXT PAGE. YOUR REGISTRATION IS NOT COMPLETE UNTIL YOU HAVE FINALIZED A PAYMENT FOR EACH CHILD. **

THANK YOU!