Summer Camp Registration Form


admiral theatre summer camp 2016 registration & payments

515 Pacific Ave., Bremerton, WA 98337 | 360.373.6810 (Administrative Offices)

Thank you for registering for the Admiral Theatre Summer Camp 2016! You are just two steps away from securing your spot in this year's camp.

1) Please complete the registration form below and click "Register" button to reserve your place.

2) Please call our Box Office at 360.373.6743 and we're happy to process payments over the phone and in person.

STUDENT DETAILS

Student Name *
Student Name
Address
Address
Phone *
Phone
Birth Date *
Birth Date
Parent or Guardian Name *
Parent or Guardian Name
This information will be used in case of an emergency and must be provided before the student can participate in any activity.
Address
Address
(if different from student address above)
Home Phone *
Home Phone
Work Phone *
Work Phone
Cell Phone *
Cell Phone
Alternative Contact Name
Alternative Contact Name
Please give the name of a friend or relative who can be contacted in case of emergency, and if parent or guardian cannot be reached.
Address
Address
(if different from above)
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
MEDICAL HISTORY / Physician Name *
MEDICAL HISTORY / Physician Name
This information must be provided before the student can participate in summer camp.
Doctor's Phone *
Doctor's Phone
Name on Insurance Policy *
Name on Insurance Policy
Date of last Tetanus shot *
Date of last Tetanus shot
No application form can be considered without a signed declaration and a deposit check. Enter student name below to complete the following declaration. I, the undersigned, being the parent/legal guardian of _________________________________________, (full name of student) declare that the information and medical details on this registration form are correct to the best of my knowledge and I hereby apply for an enrollment space at the Admiral Theatre Summer Camp as indicated (please indicate the class or section below) for my child or ward. I understand that the Admiral Theatre reserves the right to restrict admission at its own discretion.
Summer Camp Attendance | Cancellation | Participation & Medical Emergencies | Release | Privacy (Declaration) *
Summer Camp Attendance | Cancellation | Participation & Medical Emergencies | Release | Privacy (Declaration)
**ATTENDANCE** - Each class is extremely important for all students, we strongly encourage full attendance and for students to arrive on time. There is no pro-rating for missed classes. No make-up classes are offered. **CANCELLATION** - Summer/Holiday Camps: I understand that once accepted by the Admiral Theatre Summer and/or Holiday Camp I must give fourteen (14) days notice, prior to the camp start date, of my child's intention to cancel. If no notice is given, I agree to pay the camp fee in full. **PARTICIPATION AND MEDICAL EMERGENCIES** - I grant permission for my child to participate in all activities, except as indicated under ‘Medical History’, and I understand that the Admiral Theatre provides no health insurance or medical coverage and that the signing of this form acknowledges my responsibility for payment of any medical treatment which may be required while my child is participating in classes at the theatre. I further grant permission for the Admiral Theatre or its representatives to procure any and all necessary medical help for my child while they are under the supervision of the Admiral Theatre and authorize the Admiral Theatre or its representatives to permit any competent medical person to take all reasonable measures to treat any injury or sickness that my child may suffer. **RELEASE** - By digitally signing this form I release all members of the Admiral Theatre staff and any other party involved in the organization and administration of the Admiral Theatre from any liability as a result of any injury sustained in or around the Admiral Theatre venue. I grant permission for any and all photographs and video taken at the Admiral Theatre to be used by the Admiral Theatre or its representatives in displays or for advertising purposes. I understand that no personal information will be associated with any photographs or video without my consent and that no compensation is offered. I also understand that all photographs taken are the property of the Admiral Theatre. **PRIVACY** - I understand that all information supplied on this form will be kept strictly confidential and that the Admiral Theatre will never divulge any personal information to a third party without my consent. I have read and understand the above declaration.
Declaration Date *
Declaration Date
Age Group Selection *
CLICK BELOW TO RESERVE YOUR CHILD'S SPOT IN THEIR AGE GROUP. CLICK LINK AT TOP OF PAGE AFTER YOU REGISTER TO PAY IN FULL. Places are allocated on a strict first come, first served basis and deposits will be applied towards fees. *$100 deposit per child due by July 1. Balances due by July 25. (pay in full online or pay deposit / balance via phone 360.373.6743)