2025 Blend Out Performing Arts Camp Registration Form

BLEND OUT LOUD PERFORMING ARTS CAMP REGISTRATION FORM 2025

Bible Way Church of Atlas Road 2440 Atlas Road, Columbia, SC 29209
CAMPER INFORMATION
Name*

First NameLast Name
Birth Date*

MonthDayYear
Age
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Rising Grade Level*
Name of School*
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Relationship to Child
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
T-SHIRT SIZE

The Blend Out Performing Arts Camp T-Shirts are not included in the camp registration.
YOUTH
ADULT
MEDICAL INFORMATION

Check the boxes of immunizations that have been obtained and are current:
Immunizations

Polio-SalkPolio-OralTetanusDiphtheriaTyphoidSmallpox
List any unusual conditions the camp staff should know about (allergies, medications, medical conditions, restrictions, limitations, etc.)
Camper's Physician Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Number

Area CodePhone Number
BLEND OUT PERFORMING ARTS CAMP JULY 14th-18th
Blend Out will provide a summer camp for students ages 5-17 this year on the dates shown above. The camp staff will be comprised of non-profit, religious and community based personnel and local volunteers. The camp will be held in-person on July 14th-18th at The Bible Way Church of Atlas Rd 2440 Atlas Rd Columbia, SC 29209. The camp activities will include, but are not limited to music literacy, drama, motivating musical games, dance and visual arts. There will be opportunities for discussion and personal contact with some of the greatest composers, musicians, artists, and community leaders. The week-long camp concludes with a showcase where campers will share what they've learned with their parents and members of the community on Friday evening at 6:15 P.M.

In-person camp activities begin at 8:30 A.M. and will conclude at 5:00 P.M. Each camper will rotate through various classes with students within their age range.

The in-person camp fee is $85.00 + $2.00 (processing fee) (all fees are non-refundable). All payments must be made via paypal, cashier’s check or money order and can be made out to Blend Out Loud. Lunch and a snack will be provided for each camper. Detailed camp information will be provided once the camper has paid assessment.
PARENT CONSENT AND RELEASE FORM
This part of the application is to be completed and signed by a parent or guardian. Where parents are separated or divorced, this form must be signed by the parent with legal custody as established by a court.

I hereby certify that the above applicant is in good physical health and to my knowledge has no medical and/or physical conditions that would prohibit him/her from participating in any of the activities. I have read all the information in this application and I understand that the camper(s) will be supervised by the camp staff and that if serious injury or illness occurs, medical and/or hospital care will be given.

I further understand that in case of serious injury or illness an attempt will be made to notify the parent or guardian from the information furnished in this form. If it is impossible to reach the parent or guardian, I give my permission for treatment or surgery to be administered as recommended by the attending physician.

I / we acknowledge that the applicant knows and is well aware of the risks and dangers involved in the above Summer Camp Program and are assuming all risks of the injury and damage incidents to his/her participation in the camp. Further, in consideration of the permission granted to the applicant to participate in the BLEND OUT LOUD PERFORMING ARTS CAMP 2025, I / we do hereby release and discharge the BLEND OUT LOUD PERFORMING ARTS CAMP 2025, BLEND OUT LOUD, THE MIDLANDS COMMUNITY DEVELOPMENT CENTER AND THE BIBLEWAY CHURCH OF ATLAS RD from all claims, demands, actions and causes of action of any kind for any injuries sustained by the applicant and from any damages to applicant and/or applicant’s property as a result of the camp activities which will include, but not be limited to, displays, career-oriented classes, and all summer camp and other recreational activities.
PHOTO/MEDIA RELEASE

Do you give your child permission to be photographed during the camp for promotional purposes? Please check your answer in the box below.
PHOTO/MEDIA RELEASE

YESNO
PICK UP

Please provide alternate authorized individuals to pick up your child(ren).
Name and Phone Number
Name and Phone Number
I HAVE READ AND UNDERSTAND THE FOREGOING CONSENT AND RELEASE FORM AND REQUEST THAT THE ABOVE APPLICANT BE PERMITTED TO ATTEND THE CAMP SUBJECT TO THE ABOVE TERMS AND CONDITIONS.

I HEREBY CERTIFY THAT THE ABOVE NAMED STUDENT HAS BEEN APPROVED TO ATTEND THE BLEND OUT PERFORMING ARTS CAMP ONLINE AND IN-PERSON.
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Blend Out Loud Performing Arts Camp For 1$87.00
The Blend Out Loud Performing Arts Camp will be held July14th-18th on the campus of the Bible Way Church of Atlas Rd. at 2440 Atlas Rd. Columbia, SC. The hours of the camp span from 8:30 A.M. to 5:00 P.M. Our concert for the community take place on Friday, July 18th, 6:15 P.M.

Total $0.00
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BLEND OUT LOUD PERFORMING ARTS CAMP REGISTRATION FORM 2025

CAMPER INFORMATION

PARENT/GUARDIAN INFORMATION:

T-SHIRT SIZE

BLEND OUT PERFORMING ARTS CAMP JULY 14th-18th

PARENT CONSENT AND RELEASE FORM