NESA Summer Camp Registration
We are so excited to have you at our very first NESA Summer Camp! Please fill out the registration form below and complete the instructions for payment at the end of the form. You will receive a confirmation email upon completion of registration and payment. Please email jenniferchambers@nesarts.org with any questions.
Camper Name
*
First Name
Last Name
Camper Gender
*
Female
Male
Non-Binary
Transgender
Other
Camper Preferred Pronouns
*
School Name
*
Grade
*
Birthdate
*
-
Month
-
Day
Year
Date
For which session would you like to register?
*
Session 1:July 10th - 14th, 9 a.m. - 4:30 p.m.
Session 2: July 17th - 21st, 9 a.m. - 4:30 p.m.
Both Sessions
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Parent/Guardian #1 Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Occupation
*
Employer
*
Do you wish to add information for a second parent/guardian?
*
Yes
No
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Parent/Guardian #2 Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number
-
Area Code
Phone Number
Email
example@example.com
Occupation
Employer
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Emergency Pickup Information - Alternate Pickup/Release
Emergency Contact #1
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Relation to child
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Emergency Pickup Information - Alternate Pickup/Release
Emergency Contact #2
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Relation to child
Please list those people in addition to parents/guardians who are permitted to pick up your child
1:
2:
3:
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Medical Release Information
Health Insurance Provider
*
Health Insurance Policy Number
*
Primary Physician
*
Physician Address
*
Physician Phone Number
*
-
Area Code
Phone Number
Hospital Preference
*
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures), required treatment, and need for paramedic in case of emergency
*
Is your child presently being treated for any injury or sickness, or taking any form of medication for any reason?
*
Yes
No
If yes, explain:
Is your child allergic to any type of food or medication?
*
Yes
No
If yes, explain:
Does your child require a special diet?
*
Yes
No
If yes, explain:
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Terms of Agreement
New England School of the Arts and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children’s photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, FirstResponder, and/or Physician).
Parent/Guardian Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
By typing your name below, you digitally sign agreement to the above language
*
Photo Release
I hereby give permission for my child to be photographed and during the New England School of the Arts Summer Camp. I understand the photos and videos will be used to keep a journal of activities, to share during power point presentations and/or reports and for promotional purposes including flyers, brochures, newspaper, social media and on the internet. I understand that although my child’s photograph and video may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos/videos are the property of New England School of the Arts and its affiliates.
By typing your name below, you digitally sign agreement to the above language
*
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Participation Consent Form
I, the undersigned*, herby release discharge, indemnify, hold harmless and defend New England School of the Arts (NESA), its officers, employees and servants from any and all liability (claims, demands, losses, causes ofaction, suits, judgements) of any kind that I or my family may have against NESA due to death, personal injury or illness, loss or damage to property, or future causes that occur during the 2023 New England School of the ArtsSummer Camp. In the event of any medical emergency, I authorize and consent for District to act on behalf for medical care deemed necessary for the participant.
Name of Participant
*
First Name
Last Name
Name of Parent
*
First Name
Last Name
Medical Insurance Company
*
Policy Number
*
Family Doctor
*
Family Doctor Phone Number
*
-
Area Code
Phone Number
By typing your name below, you digitally sign agreement to the above language
*
Contact Phone Number
*
-
Area Code
Phone Number
Date
*
-
Month
-
Day
Year
Date
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Payment
To finalize your registration for Session 1: July 10th - 14th, please address a check of $400 to New England School of the Arts and mail to: New England School of the Arts / P.O. Box 594 / Etna, New Hampshire 03750. You will receive an email confirming we have received your payment.
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Payment
To finalize your registration for Session 2: July 17th - 21st, please address a check of $400 to New England School of the Arts and mail to: New England School of the Arts / P.O. Box 594 / Etna, New Hampshire 03750. You will receive an email confirming we have received your payment.
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Payment
To finalize your registration for both sessions (July 10th-14th and July 17th-21st), please address a check of $800 to New England School of the Arts and mail to: New England School of the Arts / P.O. Box 594 / Etna, New Hampshire 03750. You will receive an email confirming we have received your payment.
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Thank You!
Thank you for completing registration for NESA Summer Camp. You will receive an email confirming your registration and a reminder with payment instructions. Please email jenniferchambers@nesarts.org with any questions.
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