Song-Writing Camp 2021
Taught by Kadie Kelly
Parent 1 Name
*
First Name
Last Name
Parent 2 Name
*
First Name
Last Name
Participant Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 1 Email Address
*
example@example.com
Parent 2 Email Address
example@example.com
Home Phone Number
*
-
Area Code
Phone Number
Cell Phone Number Parent 1
*
-
Area Code
Phone Number
Work Phone Number Parent 1
-
Area Code
Phone Number
Cell Phone Number Parent 2
*
-
Area Code
Phone Number
Work Phone Number Parent 2
*
-
Area Code
Phone Number
Emergency Contact Name
*
First Name
Last Name
Emergency Contact's Relationship to participant/s
*
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Emergency Contact 2
*
First Name
Last Name
Emergency Contact 2's Relationship to participant/s
*
Phone Number
*
-
Area Code
Phone Number
Participant 1: Full Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Grade Entering Fall 2021
*
School Child Attends
*
Is child allergic to anything?
*
Name any allergies
Are any special accommodations needed?
*
Any particular goals participant has for this session?
*
Please mark which week(s) your child/ren would like to participate. Week starting:
June 7th
June 14th
June 21st
Health Insurance Name
Health Insurance Policy Number
Name of Doctor
*
First Name
Last Name
Doctor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor Phone Number
-
Area Code
Phone Number
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