Arizona Rose Youth Theatre Registration Form

"SUMMER STOCK LITE"

2023 CAMP PROGRAM

Student 1
CAMP SELECTION FOR STUDENT 1

"BROADWAY MELODIES" - ages 6 to 11"THE BROADWAY EXPERIENCE" - ages 12 to 17
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Gender*

Student 2 (Click here only if registering two students, otherwise click NEXT below)
CAMP SELECTION FOR STUDENT 2

"BROADWAY MELODIES" - ages 6 to 11"THE BROADWAY EXPERIENCE" - ages 12 to 17
Student's Name (2)

First NameLast Name
Birth Date (2)

MonthDayYear
Grade (2)
Gender (2)

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name*

First NameLast Name
Daytime Phone*

Area CodePhone Number
Evening Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Please list any current medications, medical conditions, recent injuries, and food, drug or other allergies:
Informed Consent and Acknowledgement

I (we) hereby release, forever discharge and agree to hold harmless The Arizona Rose Arts Organization, its principals, employees, agents and assigns, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the undersigned’s child(ren) that occur while they are participating in any classes or activities conducted by The Arizona Rose Arts Organization. The undersigned further hereby agrees to hold harmless and indemnify The Arizona Rose Arts Organization, its principals, employees and agents for any liability sustained by said participant, including expenses incurred attendant thereto. The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify The Arizona Rose Arts Organization, its directors, employees and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant.
*

ACCEPTDO NOT ACCEPT
Permission to Video and Photograph

I hereby grant permission for my child to be video recorded and/or photographed while participating in programs and activities of Arizona Rose Arts Organization. It is my understanding that video and photographs will be used for educational, training and promotional purposes only. I may revoke this permission at ant time be sending a letter to Arizona Rose Arts Organization.
*

ACCEPTDO NOT ACCEPT

PAYMENT

REGISTRATION FEE$180.00

Quantity

Total $0.00

Credit Card

Confirmation

BY ACKNOWLEDGING AND SIGNING 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
Should be Empty:

"SUMMER STOCK LITE"

Credit Card