POPeretta! Summer Program Registration Form

Pacific Opera Project: POPeretta! Summer Program Registration From

Please complete the registration form below.
Participating Child's Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemaleNon-binaryPrefer not to sayOther
Child's grade (For school year 2023-2024)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethinicity

First Nations, Indigenous or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite or CaucasianMultiracialPrefer not to sayOther
Parent/Guardian Information
Name*

First NameLast Name
Cellphone Number*
(000) 000-0000
Alt. Phone Number
(000) 000-0000
E-mail*
example@example.com
Additional Parent/Guardian Name

First NameLast Name
Cellphone Number
Alt. Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship To Child*
Phone Number*
(000) 000-0000
Alt. Phone Number
Additional emergency contact:

First NameLast Name
Relationship to child:
Phone Number
Please enter a valid phone number.
Alt. Phone Number
Please enter a valid phone number.
Does this child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the child prescribed an inhaler or EpiPen? If yes, please explain.
Do you have any other important information about your child you would like to share?
Ex: Other medical needs, important behavioral traits, IEPs, stressors, important information for in the event of an emergency
How did you hear about the POPeretta Summer Program?
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Pacific Opera Project during this activity. In exchange for the acceptance of said child’s candidacy by Pacific Opera Project, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Pacific Opera Project and all its respective staff members, volunteers and representatives from any and all liability for injuries to said child arising out program sessions. In case of injury to said child, I hereby waive all claims against Pacific Opera Project including all staff, volunteers, affiliates, participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. I understand that this activity poses a small risk of injury to participants.
Medical Release and Authorization As Parent and/or Guardian of the named minor child, I hereby authorize that in the event of a medical emergency that requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, undue pain, or suffering or discomfort, Pacific Opera Project may contact emergency services. This authorization is granted only after a reasonable effort has been made to reach me and the named emergency contact by Pacific Opera Project. I understand that Pacific Opera Project staff contain only a basic knowledge of first aid, and are not certified to diagnose or treat any participating minors. Release of the minor child's basic medical information to a medical professional in the event of a serious illness or injury is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. In the event of an emergency arising out of serious illness or significant accidental injury, I understand that every attempt will be made by the medical team to contact me in the most expeditious way possible.
Confirmation BY PROVIDING AN ELECTRONIC SIGNATURE AND CLICKING "SUBMIT FORM" 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

POPeretta! Program Registration Fee*
prevnext( X )
Registration Fee
$50.00

Total

$0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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Pacific Opera Project: POPeretta! Summer Program Registration From