Summer Camp 2018

Student Information

Student's Name*

First NameLast Name

Birth Date

MonthDayYear

Age*

School Attending*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Mother's Name*

First NameLast Name

Cell Number*

Area CodePhone Number

E-mail*

Father's Name

First NameLast Name

Cell Number

Area CodePhone Number

E-mail

example@example.com

Does your child have any allergies, chronic illness, medical conditions or take any medications? If yes, please describe.*

Please provide any additional information you would like us to know here.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Shanti Belasco Glynn during the musical theatre workshop. In exchange for the acceptance of said child’s candidacy by Shanti Belasco Glynn, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Shanti Belasco Glynn and all her respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected workshop sessions.

In case of injury to said child, I hereby waive all claims against Shanti Belasco Glynn including all teachers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Shanti Belasco Glynn and her affiliates including other teachers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the workshop session.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Cost of each workshop is $200 per child. (10% sibling discount)

You may Venmo $200 to Shanti-BelascoGlynn, Paypal her at shantielisa@earthlink.net or just bring a check on the first day of class.

Which workshop are you signing up for?

Payment

Workshop Fee$283.00

Quantity

Total $0.00

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

Musical Theatre Summer Camp Registration