Camp Nia Registration Form
Camp will be held from July 18-29, 2022...Camp Hours: 9:30 am - 3:00 pm
Camp Nia is open to girls ages 11-14 and includes lunch and snacks. With an Afrocentric foundation, the camp addresses self-esteem, self-confidence, self-control, self-expression, cultural awareness, health & exercise, and proper diet via the performing arts. Four classes are offered: vocals, dance, drama, and stage design, and the girls select two classes to focus on for the duration of the camp. Classes are taught by experienced professionals who are assisted by high school and/or college students experienced in the craft being taught. The entire two weeks of Camp Nia are spent preparing for a culminating performance which is open to the community. The camp registration fee is $100 and due no later than July 15.
Please complete the registration form to enroll your daughter in the program.
Participant Information
Participant Name
*
First Name
Last Name
Age
*
Please Select
10
11
12
13
14
Birth Date
*
-
Month
-
Day
Year
Date Picker Icon
Grade Level this for the 2022-2023 school year.
*
Please Select
5
6
7
8
9
10
Class Selections
Girls are able to choose 2 classes to focus on. Please select your daughter's choices; we will do all we can to ensure your daughter is placed in the classes of her choice.
1st Choice
*
Please Select
Singing
Dance
Acting
Set Design (Art)
2nd Choice
*
Please Select
Singing
Dance
Acting
Set Design (Art)
Alternate Choice
Please Select
Singing
Dance
Acting
Set Design (Art)
Attendance Expectation Acknowledgment
Daily attendance is critical. Inconsistent attendance and/or excessive tardiness is disruptive to the camp in preparation for the performance. We rely on parents to ensure their daughter arrives to and is picked up from camp on time.
I agree to make every effort to have my daughter to camp on time and to pick up on time.
*
Please Select
I AGREE
I DISAGREE
Parent Information
Parent/Guardian #1
*
First Name
Last Name
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone #
*
Other Phone #
E-mail
*
example@example.com
Parent/Guardian #2
First Name
Last Name
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone #
E-mail
example@example.com
Emergency Contacts
Emergency Contact #1
*
First Name
Last Name
Relationship
*
Phone Number
*
Emergency Contact #2
*
First Name
Last Name
Relationship
*
Phone Number
*
Medical Information
Does your daughter have any medical issues we need to know about?
*
Please Select
YES
NO
If yes, please explain. If no, please type N/A.
*
In the event of an emergency, do we have your permission to seek medical care for your daughter?
*
Please Select
YES
NO
If yes, what is your hospital of choice? If no, please explain what you would like us to to instead.
*
Medical Insurance Carrier, If none, please indicate "NONE" in each of the boxes below.
*
Policy #
*
Doctor's Name:
*
Doctor's Phone #
*
Informed Consent
All Camp staff are mandated child abuse reporters. Should a staff member learn that your daughter is being harmed, staff is mandated by law to contact Child Protective Services (CPS) without notifying the parent prior to doing so. Should we learn your daughter is harming herself, or considering harming herself, we will notify you immediately. Do you understand and agree with your Informed Consent?
*
Please Select
YES
NO
COVID Policy
At an effort to keep all campers and staff safe and free from COVID, all campers and camp staff (regardless of vaccination status) will be required to present a negative COVID test each Monday of camp. Tests will need to be taken within 24 hours of attending the camp. Tests can be provided to campers, if needed.
I acknowledge the COVID policy and will ensure my daughter presents a negative COVID test each Monday of camp.
Please Select
Yes
No
Media Release and License
I hereby grant Sisters of Nia, Incorporated an irrevocable License to use my daughter’s photograph, video, voice, or likeness of any kind, now or at any time in the future throughout the world in any manner it so chooses and in any medium now known (print, radio, TV, internet, etc.) or later developed, in an unlimited number of times in perpetuity. This includes, without limitation, media, marketing, advertisements, and any other promotional material it wishes. I also acknowledge that Sisters of Nia, Incorporated is under no obligation to use my daughter’s photograph, video, voice, or likeness of any kind, in any materials or manner it so chooses. I agree that no fees, commissions or royalties are to be paid to me or my daughter for the use of her photograph, video, or likeness of any kind. I further agree to waive any right to inspection or approval of the use of my daughter’s photograph, video, voice, or likeness of any kind. Additionally, I acknowledge that Sisters of Nia, Incorporated may rely on this permission and waiver at a substantial cost and I hereby agree not to assert any claim of any nature whatsoever against anyone relating to the exercise of the permissions granted hereunder. I have read this Release and License and I fully understand the meaning and importance of its contents. I further acknowledge and agree that I have exclusive right and authority to sign this Release and grant this License.
*
Please Select
YES
NO
Camp Fee
There is a $100 program fee which is due no later than July 15th. Payments are accepted via CashApp ($Ssitersofnia), Venmo (@Sisters-of-nia), or PayPal (paypal.me/Sistersofnia). Please note, payments on PayPal require an additional $5.00 fee. Payments can also be made via cash or check on July 15th.
I agree to pay the $100 program in full by the due date.
*
Please Select
YES
NO
Parent Signature
Please sign as your consent for your daughter to participate in Camp Nia.
*
Clear
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform