REGISTRATION FORM

(Please print this page and mail w/ fee to address at bottom)

 

         Summer 2010 Comedy Acting Daycamps

Name: _______________________________________ Age: ______ Grade: ______

Address: ______________________________________________________________
                                 STREET                                  CITY                                     ZIP

E-mail address: ________________________ Daycamp date ___________________

Experience (check one):      Previous Acting Experience: ____ Beginner: ____

Daycamp type (check one):       Full Day: ____ Half-Day: ____ ===

Parents: I look forward to providing your child with an exciting, fun, and safe daycamp experience.

We do not participate in any dangerous physical activities. However, in the event of an emergency, please provide me with the following information:

Parents’ Names: __________________________________________________________

Phone Numbers:  HOME)________________ WORK) _______________ CELL) ________________

Emergency Contact (other than parent): ____________________________ Phone: _____________

Insurance Company: ________________________________________________

Policy Number: ________________ Student’s health concerns or allergies (food, drugs, etc.):         

 

__________________________________________________________________________________

If parents or emergency contact cannot be reached, I authorize Helen Kearney Konen to seek medical assistance for my child. I agree to hold Helen Kearney Konen and Theatre Charlotte harmless for personal illness or injury.

My child agrees to exercise care in the facility and I agree to reimburse Theatre Charlotte for any personal breakage, damage or loss of property due to his/her negligence.

________________________________________________             ____________________
               Parent/Guardian Signature                                                         Date

Daycamp Dates:        June 21-25                         June 28-July 2                          July 5-9   

 
To Register:
Please send form and $75 ( non refundable deposit applied toward tuition) to secure seat in camp.
Balance of tuition is due 2 weeks prior to camp date.

Make check payable to Helen Kearney Konen and send form and deposit to:

Helen Kearney Konen
2936 Saintfield Place
Charlotte, NC 28270