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Summer Youth Camp Registration

SUMMER DAY CAMP REGISTRATION

To Register - Please complete all applicable fields below. All information is confidential.

Step 1 of 4

25%

Applicant Name*
FirstLast
Email Address*
Cell/Home Number (Best Contact)
Gender
- Male
- Female
Date of Birth
School Name & County
Which Session Would You Like to Attend?*
- Session 1 – June 3-7
- Session 2 – June 10-14
- Session 3 – June 17-21
- Session 4 – June 24-28
- Session 5 July 8-12
- Session 6 – July 15-19
- Session 7 – July 22-26
- Session 8 – July 29- Aug 8
T-Shirt Size (child)
- S
- Med
- Large
- X-Large
New Actor's Breakthrough Student?
If "NO", how long a student?
How did you hear about the camp?
Allergies or special needs, including medication as well as disabilities:

Parent/ Guardian Information
Mother's Name
FirstLast
Mailing Address
Street AddressCityStateZIP Code
Cell/Home Number (Best Contact)
Work Phone Number
Father's Name
FirstLast
Mailing Address
Street AddressCityStateZIP Code
Cell/Home Number (Best Contact)
Work Phone

Emergency Contact (EC) & Medical Information:
EC's Name
FirstLast
Relationship to student:
Cell/Phone Home
Cell/Phone Home
Doctor's Name
Doctor's Phone
Hospital Preference
Dentist's name
Dentist's phone

Electronic Permission
I give permission for my child and/or myself to participate in the above-mentioned Actor’s Breakthrough Young Actor Camp:
- Yes, I give Permission
Eneter your name to approve
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