Summer Spotlight Registration

Registration

Summer 2023
Choose a session. (If registering the same child for two sessions, check both) To register different children you must fill out separate forms.*

Entering PreK - Grade 1 (July 10-14 9 AM-NOON)Entering PreK-Grade 1 (July 17-21 9 AM-NOON)Entering Grades 2-8 (July 11-22 9 AM - 4 PM THIS IS A TWO WEEK PROGRAM)
IF IN GRADE 5-8: Would participant want to participate in a "Tech Crew" track during the 2 weeks if it were offered? (focusing on costuming, sets, lighting, sound, etc.)*

YESNONOT APPLICABLE (PreK-1)
If we added programming for August 1 through 12, I would be interested in...

1 Week PreK-Grade 1Two week Full day for Grades 3-8One Week Full Day for Grades 3-8
PARTICIPANT INFORMATION:

(One child per form)
Participant Preferred First Name*
First Name
Participant Last Name*
Last Name
Participant Preferred Pronouns*

she/herhe/himthey/them
Grade in September*
Date of Birth*

MonthDayYear
(mm-dd-yyyy)
Participant Cell Phone Number*
123-456-7890
Participant Email*

Confirmation EmailConfirm Email
Home Address*

Street Address

Apt #

CityState

Zip Code
Does your child have a friend they would like to be paired with? (or enter "no")*
.
Name of School*
T-Shirt Size*
RESPONSIBLE ADULT (1) CONTACT INFORMATION:
Responsible Adult Name*

First NameLast Name
Address*

Street Address

Apt #

CityState

Zip Code
Cell Phone Number*
123-456-7890
E-mail*

Confirmation Email
RESPONSIBLE ADULT (2) Emergency Contact Information
(2) Responsible Adult Name*

First NameLast Name
(2) Cell Phone Number*
123-456-7890
(2) E-mail Address ONLY IF THEY WANT TO RECEIVE ALL EMAIL COMMUNICATIONS

Confirmation Emailexample@example.com
(#1) : ALTERNATE PICK/UP & RELEASE

Please list any persons you authorize to pick up your child from camp. ID required & must match the designated pick-up.
Name

First NameLast Name
Cell Phone Number
123-456-7890
Relationship to Child
(#2) ALTERNATE PICK/UP & RELEASE
Name

First NameLast Name
Cell Phone Number
123-456-7890
Relationship to Child
Please list any other persons who you give permission to pick up your child. Include name, cell phone number and relationship to your child.
Parent/ Guardian Initials:*
By initialing above, I give PCA Summer camp counselors and volunteers permission to release my child to the contacts listed and will notify the administration in writing if any changes occur.
Terms of Agreement: Photo Release

I hereby give permission for my child to be photographed during the PCA Summer Spotlight. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/ or reports to our donors and for promotional purposed including flyers, brochures, newspaper and on the internet. His or her identity will not be disclosed.
I agree to the terms of the photo release agreement:*

YesNo
Parent Guardian Initials*
By initialing above, I certify that I agree (selected"yes") or disagree (selected "no") to the terms of the photo release agreement
How did you hear about PCA Summer Spotlight?*
Signature Required:

**Pepperell Community Arts is not responsible for lost or damaged personal property. All events are subject to change.
Parent/ Guardian Signature*

Clear
Name of Parent/ Guardian signing*

First NameLast Name
Today's Date*

MonthDayYear
Date
YOUR REGISTRATION IS NOT COMPLETE UNTIL YOU MAKE YOUR PAYMENT. PAYMENT MUST BE RECEIVED WITHIN 10 DAYS TO GUARANTEE YOUR SPOT.
Payment (must be received within 10 days to guarantee spot)*

Online through PayPal (can pay using credit or debit card without having PayPal account)mailing a check
Please list the date by which we should expect to receive payment*
HOW TO PAY ONLINE

After clicking the Submit Form button below, you MUST GO BACK TO THE PCA WEBSITE to the same page where you found this form. There will be a button that says PAY HERE. Click the button and it will take you to PayPal.

YOU DO NOT NEED A PAYPAL ACCOUNT TO PAY ON PAYPAL!

On the PayPal site, below where it says sign in, it says, "pay with a debit or credit card". This is where you click to pay if you do not have or do not want to use your PayPal account.
I have read the above instructions on how to pay online.*

I agree
Should be Empty:

Registration

PARTICIPANT INFORMATION:

RESPONSIBLE ADULT (1) CONTACT INFORMATION:

RESPONSIBLE ADULT (2) Emergency Contact Information

(#1) : ALTERNATE PICK/UP & RELEASE

(#2) ALTERNATE PICK/UP & RELEASE

Terms of Agreement: Photo Release

Signature Required: