The Kirby Summer Art & Theatre

PERSON COUNTY RECREATION, ARTS AND PARKS REGISTRATION FORM

Programs:                                        Camp Codes:

                                          Youth Theatre                                        YTHTR

                                          Children’s Theatre                                  CTHTR

                                          Drama Camp                                         DRAMA

                                          Art Camp I                                             ART 1

                                          Art Camp II                                            ART 2

                                          Guitar Camp                                          GUITAR

                                          Voice Class                                          VOICE

 Participant (s) Last Name____________________________________________________

Address: ____________________________City: ________________Zip: _____________

Home Phone________________________ Parent Work Phone___________________

Emergency Contact____________________________ Day Phone________________

 

Camper's

Camp ID

Camper's

Rising

Sex

T-Shirt Size

Fee

First Name

(include all)

Birth Date

Grade

 

(adult or youth)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Every participant must have insurance.  You may purchase Recreation

Camp

 

insurance policies for $6.00 per participant through the Recreation Dept. 

 

 

Insurance

 

 

 

 

 

        Total Enclosed

 
                     

 

Parent/Guardian Signature:___________________________________________________________

 

Private Insurance Carrier:__________________________ Policy Number______________________

  I give my permission and grant to the Person County Parks and Recreation Dept. the right to make pictures

and sound recordings of my child and the right to use such pictures and sound recordings, including the right to

identify my child’s name, likeness, voice and words, in television, film, newspaper, magazine, internet, and other

media of any form, for the purposes of advertising and communicating the purpose and activities of the Person County

Parks and Recreation Dept. and for the purpose of applying for funds to support those purposes and activities.

            I (we) hereby release and hold harmless this organization and individuals running this camp from any and all responsibilities for accidents or losses incurred by my child at the location of the camp or traveling to and from the

 camp. 

Parent/Guardian Signature_________________________________________ Date_______________________

 To be filled out by Office Staff

Total Paid_______________ Accepted by_____________ Date_________________ Receipt_____________