TLD YouthLab 2023 Registration

Camper's Name*

First NameMiddle NameLast Name

Which camp will you be attending?

Birth Date*

MonthDayYear

Age*

Grade in the Fall

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian E-mail*

Mobile Number*

Area CodePhone Number

Work Number

Area CodePhone Number

Emergency Contact*

First NameLast Name

Emergency Contact Number*

Area CodePhone Number

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

Insurance Policy Number

Medical information is needed in the event of an emergency and the parent/guardian cannot be reached. Marking the selection below will act as your signature & authorization for emergency medical care

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.

I give permission and consent for my child (listed on this application) to allow photographs to be taken during YouthLab camp session activities. I further give permission and consent that any such photographs may be published and used by TheatreLab Dayton to illustrate and promote the camp experience. I release TheatreLab Dayton / Dare 2 Defy Productions from all claims, demands, and liabilities whatsoever in connection with above. Marking the selection below will act as your signature & authorization for show-related photographs.

I authorize TheatreLab Dayton to utilize photos of my child for promotional or marketing materials.

How did you hear about our Summer Camp?

My Products

Discovery Camp - Ages 6-10 (Early Bird)$150.00

1 week - July 10-14

Quantity

Explorers Camp - Ages 8-12 (Early Bird)$150.00

1 week - July 17-21

Quantity

Seize the Day! A YouthLab Cabaret - Ages 10-17 (Early Bird)$300.00

2 weeks - July 24 - Aug 4

Quantity

Extended Care (per week)$50.00

1 week - 3-5pm

Quantity

Camp Scholarship Donation$1.00

Donations go toward YouthLab Scholarship

Quantity

Enter coupon

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.

YouthLab Summer Camp 2023