LMSM Registration
These forms are required for your child to attend camp.
Camper's Information
Camper Name
*
Nickname
Entering Grade in 2024/25
*
Please Select
4th
5th
6th
7th
8th
9th
School Camper Attends
*
Please Select
JM
OIS
Stanley
Del Ray
Glorietta
Sleepy Hollow
Wagner Ranch
Camino Pablo
Los Perales
Rheem
Burton Valley
Lafayette
Springhill
Other
Instrument
*
Please Select
flute
oboe
clarinet
bassoon
saxophone, alto
saxophone, tenor
saxophone, baritone
trumpet
f horn
trombone
euphonium
tuba
percussion
violin
viola
cello
double bass
Playing Experience
Please Select
beginner (no prior experience)
intermediate (1-2 school years experience)
advanced (3-4 school years experience)
T-Shirt Size
Please Select
YS
YM
YL
AS
AM
AL
AXL
AXXL
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
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Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
example@example.com
Cell Phone
*
Home Phone
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work/School Name
*
Or enter N/A if not applicable
Parent's Work/School Phone
Parent's Work/School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would you like to be reached while your child is at camp?
*
Cell Phone
Work Phone
Home Phone
Parent Information
Parent/Guardian 2
Parent/Guardian 2
*
First Name
Last Name
Relationship to Child
*
E-mail
*
example@example.com
Cell Phone
*
Home Phone
*
Home Address Same as Parent/Guardian 1?
Yes
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work/School Name
*
Or enter N/A if not applicable
Parent's Work/School Phone
*
Parent's Work/School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would parent/guardian 2 like to be reached while your child is at camp?
Cell Phone
Work Phone
Home Phone
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. Persons listed must be within one hour of camp, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Heading
Emergency Contact #1
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Secondary Phone Number
*
Relationship to Child
*
Heading
Emergency Contact #2
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Secondary Phone Number
*
Relationship to Child
*
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Medical / Health Information
Name of Physician or Clinic/Hospital
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
*
Food
Medication
Environmental
Please list and explain any allergies
*
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
*
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
*
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?
*
Yes
No
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
*
Yes
No
Please explain
*
0/150
If yes, does this medication, food supplement, or medical food need to be administered at camp?
*
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
*
0/150
List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.
*
0/200
Additional Medication
Check all that apply
Prescription medication
Nonprescription medication
Topical product or lotion
Food supplement
Modified diet
Name of medication
*
Exact dosage
*
To be administered at the following times
*
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Payment and Statement of Understanding
Lamorinda Summer Music has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
*
Type first and last name above to consent
Sign Document
*
Date Signed
*
-
Month
-
Day
Year
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Lamorinda Summer Music
June 24-28, 9am-3:30pm
$
675.00
Before-Camp Care
8am-9am, every day
$
100.00
After-Camp Care
3:30-5pm, every day
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Daily Lunch Box
All proceeds benefit the Campo Music Boosters
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
SUBMIT
Should be Empty: