Maryland Registration Form-Summer Camps 2018

STUDENT REGISTRATION
Montgomery County Summer Camps 2019

1. General Information
(Please fill out a separate form for each child.)

* Indicates required field

Child's Name *

First

Last

Gender *

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

Parent/Guardian's Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Camp *

Dramatic Kids! Jul 8 - 12, 2019, Cashell ES, $325 Act It Out! Jul 8 - 12, 2019, Cashell ES, $325 Dramatic Kids! Jul 15 - 19, 2019, Hallie Wells MS, $325 Act It Out! Jul 15 - 19, 2019, Hallie Wells MS, $325 Dramatic Kids! Aug 5 - 9, 2019, Jane E. Lawton Rec. Ctr., $325 Act It Out! Aug 5 - 9, 2019, Jane E. Lawton Rec. Ctr., $325

Name of person picking child up from camp *

Relationship to the child *

2. Medical & Emergency Information

Allergies (if applicable) *

Primary Emergency Contact *

First

Last

Primary Emergency Contact Phone Number *

Secondary Emergency Contact *

First

Last

Secondary Emergency Contact Phone Number *

Please list any special assistance or accomodations needed *

3. Photo Release Agreement

I grant to CARE Actor, LLC the right to use photographs of my son/daughter and my family in connection with the above-identified event. I authorize CARE 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 CARE 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 CARE Actor, LLC its owners and operators or en route to or from any of said premises.

Hold Harmless Agreement *

I've read the above and agree.

Additional Comments *

Choose your camp!

1. General Information(Please fill out a separate form for each child.)

2. Medical & Emergency Information

3. Photo Release Agreement

4. Hold Harmless Agreement

1. General Information
(Please fill out a separate form for each child.)