2023 Camp Shine Registration Form

Camp Shine 2023 Registration Form

This Shine MSD Summer Camp will provide middle and high school students an opportunity to participate in a range of creative exercises from drama & musical theatre to songwriting or art. Classes will be led by the professional instructors at Barclay Performing Arts. Students from both sessions will be invited to collaborate for a finale performance at the end of camp!
DATES & TIMES

SESSION 1: JUNE 19 - 30

MONDAY - FRIDAY 9:00 AM - 2:00 PM

BYOL (Bring your own lunch)

SESSION 2: JULY 17 - JULY 28

MONDAY - FRIDAY 9:00 AM - 2:00 PM

BYOL (Bring your own lunch)

FINALE CELEBRATION

Session 1 Students: Friday, June 30, 4 - 6 PM

Session 2 Students: Friday, July 28, 4 - 6 PM

LOCATION

BOCA BLACK BOX CENTER FOR THE ARTS

8221 Glades Rd #10, Boca Raton, FL 33434
Participant Name*

First NameLast Name
Birth date*

MonthDayYear
Date
FemaleMaleNon-binaryPrefer not to disclose
Hispanic or LatinoWhiteBlack or African AmericanAsianAmerican Indian or Alaskan Native
What grade level you will be entering for the 2023-2024 calendar year?*
What school will you be attending?*
Session 1 (June 19 - 30)Session 2 (July 17 - 28)
YesNo
Participant Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Participant Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Name*

First NameLast Name
Relationship*
Emergency Contact's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
SmallMediumLargeX-Large
Do you have any allegeries, food restrictions, medical conditions or disabilities? If yes, please describe.*
I agree to attend all dates as listed above including the final performance on 6/30 or 7/28. Please list and explain any attendance conflicts with dates*
Type "Yes" if you agree
Is there anything else you would like us to be aware of or take into consideration?
How did you hear about our camp?*
Type "Yes" if you agree
RELEASE STATEMENT:I understand that the SHINE MSD Summer Camp is held at Boca Black Box Center of Arts, and I agree to abide by all its policies. I give permission to use photographs & videos of my child or me for any and all promotional purposes.I/We as an individual or as a parent or guardian of the participants named herein, assume all risk and hazards incidental to the activities and release from responsibility and agree to indemnify and hold harmless SHINE MSD, their officers, directors, independent contractors, volunteers, on site staff and all employees for any illness and injury to me or my children or family members occurring during his/her/our participation in any activities or use of any facilities at/or conducted by SHINE MSD. Bullying or harassment of any form will result in a dismissal from the program. Signing this document means you have read and agree to the terms listed herein.*

I agree
Signature*

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Attendance is limited. Once your application is submitted Shine MSD will email you with confirmation of your registration. Please reach out to Mkochan@shinemsd.org with any questions.
Shine MSD has provided over 50 free workshops and camps to students across south Florida. Please consider donating to our organization and helping us continue creating impacts through creative art therapy.

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Camp Shine 2023 Registration Form