Clone of Virtual Summer Camp Registration Form

Youth Music Production Program

Please complete the registration below
Participant Information
Last Name*
First Name*
Middle Name
Gender*

MaleFemale
Date of Birth

MonthDayYear
Date
This participant is an adult
Contact Information
Address*
City*
State*
Zip*
Phone number*

Area CodePhone Number
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Parent/Guardian Information

List first and second choice, not all requests are quaranteed.
First Name*
Last Name*
Phone number*

Area CodePhone Number
Email*
Birth Date

MonthDayYear
Occupation
Employer
Relationship
Photography/Videography
I give permission for my child to be photographed and videotaped during program activities.

YESNO
Signature

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All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Electronic signature, please initial*
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Youth Music Production Program