High School Musical Theater Day Camp Registration 2022

Yellow Brick Theater: Musical Theater Intensive Registration

Grades 9-12 (Fall 2022)
Camp Information

Who: Students entering 9th-12th grade in Fall of 2022

What: Join us as we dive into a week of acting, voice, and movement while exploring some of Broadway’s top musical hits! In this musical theater camp, students will work with teaching artists and explore musical theater techniques through performance. Campers will apply their knowledge to new material in preparation for the showcase performance on the last day of camp.

Where: Restoration Church
63 E Franklin St.
Centerville, OH 45459

When: July 25th-29th, 2022
10am - 4pm

Tuition: $220

Please contact us at info@yellowbricktheater.org or call Dionne Meyer at
(831) 233-8437 with any questions.
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade (in Fall)*
Pronoun*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name*

First NameLast Name
Home Number

Area CodePhone Number
Mobile Number*

Area CodePhone Number
E-mail*
myname@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Email*
myname@example.com
Medical Information
Physician's Name*

First NameLast Name
Physician's Phone Number*

Area CodePhone Number
List all known medical conditions, including allergies to food or medications.*
List any and all over-the-counter and/or prescription drugs taken regularly.*
Medical Insurance Company*
Insurance Policy Number*
This information is needed in the event your child must be taken to the hospital and the parent/guardian cannot be reached.
Authorization for Emergency Care to a Minor

As the Parent/Guardian of the aforementioned child, I authorize such diagnostic, medical, and/or surgical treatment of my child as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury, by licensed emergency medical professionals.
Authorization of Emergency Care*

Yes
Photo Release Statement

I give permission and consent for photographs to be taken of my child during camp session activities. I further give permission and consent that any such photographs may be published and used by Yellow Brick Theater to illustrate and promote the camp experience and its programs. I release Yellow Brick Theater from all claims, demands, and liabilities whatsoever in connection with the above.
Photo Release*

YesNo
Camp T-Shirt Order
Youth Size

SmallMediumLarge
Adult Size

SmallMediumLargeExtra LargeExtra Extra LargeExtra Extra Extra Large
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Payment

Payment of $220 due by June 30th.

Checks may be made payable to Yellow Brick Theater. Payment plans are available. A DISCOUNT is available for siblings. Deduct $25 off the price of tuition for the second child enrolled. For a third and/or fourth child, deduct $50 off of each child's tuition.

REFUND POLICY: A full refund is available if YBT is notified before June 13th. After June 13th, a 50% refund will be given.

Check/cash payments may be sent to:

Yellow Brick Theater
c/o Dionne Meyer
3746 Mesquite Dr.
Beavercreek, OH 45440

A $25 fee will be charged for returned checks.

Please select from the following options:
Payment Method*

CheckCashPayPalCredit Card
PLEASE HIT THE ORANGE SUBMIT BUTTON AT THE BOTTOM OF THIS FORM AS WELL AS HITTING THE GREEN SUBMIT BUTTON FOR PAYMENT!
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Yellow Brick Theater: Musical Theater Intensive Registration

PLEASE HIT THE ORANGE SUBMIT BUTTON AT THE BOTTOM OF THIS FORM AS WELL AS HITTING THE GREEN SUBMIT BUTTON FOR PAYMENT!