Registration GNAT-TV Spring Camp 2023

GNAT-TV 2023 Spring Break Camp Registration

6378 Vermont Rte 7a #1, Sunderland, VT 05250
Monday, April 17th through Friday, April 21st, 9am-3pm, Ages 9-14
Student Info:
Student Name*

First NameLast Name
Birth Date:*

MonthDayYear
Gender:*

MaleFemaleNon-Binary
What school does your child attend?*
Address:*
City:*
State:*
Zip:*
Parent/Legal Guardian Info:
Parent/Legal Guardian Name(1):*

First NameLast Name
Relation to Student:*
Emergency phone number while camp is in session:*

Area CodePhone Number
Parent/Guardian (1) email:*
Parent/Legal Guardian Name (2):

First NameLast Name
Relation to Student:
Parent/Guardian (2) email:
Parent/Legal Guardian (2) Emergency Phone Number:

Area CodePhone Number
Health Information/Waivers:
Emergency Medical Waiver: In the event of an emergency, if I cannot be reached, I grant permission for GNAT-TV staff to seek medical treatment for my child.*

Yes
Please list any activities the student should be restricted from. Any health conditions that would require special attention or medication while at camp. Any known allergies (e.g. bees, peanuts, dairy, eggs, etc).*
GNAT-TV Staff expect students to show the utmost consideration for the feeling for others. We strive for cooperative and joyful interactions. In the event we experience behavioral issues with your child, we may contact you and ask that your child leave the program early. GNAT-TV reserves the right to dismiss from camp any child whose behavior is inappropriate. In such event, no refund will be given.*

Yes-I agree
I agree that photos/video of my child may be taken and used for television broadcast, promotional purposes, including web and printed media.

Yes
Students Other Information:
How did you hear about GNAT-TV's Spring Break Camp?*
What are your student's interests?*

WritingPerforming ArtsFilm MakingMusicGraphic Art/Photo/Painting/DrawingCookingStorytellingCostume and Set DesignDirecting/ProducingCamera Operator/Lighting/AudioReadingAnimationOther
Is there anything else we should know about this sudent to make the program more fun and accessible? e.g. about learning style, academic needs, social or emotional factors.*
Has the child attended a GNAT-TV workshop/camp in the past?*

YesNo
Payment Information

Payment must be received by Friday, April 14th.

Camp

Make Your Own Studio Show! 4/17 – 04/21 $325.00

Quantity

Total $0.00

Payment Method

	What is PayPal?

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian Signature
Electronic signature, please initial:*
Electronic signature, First & Last Name:*
I acknowledge that my initials and name typed here on this form are as legally binding as my printed signature, and, further, that I am the parent and/or legal guardian of the "listed student" and over the age of 18. I also attest to the accuracy of all information entered on this form and authorize qualified personnel to apply general medical treatment to the "listed student." In addition, I agree that the "listed student" will only be released from camp into the authority of the guardian listed on this form. I, further, certify that the "listed student" has my permission to attend this camp and participate in all camp activities.
Should be Empty:

GNAT-TV 2023 Spring Break Camp Registration

Student Info:

Parent/Legal Guardian Info:

Health Information/Waivers:

Students Other Information:

Payment Information

Parent/Guardian Signature