Registration Medical Information Form
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For office use only: T.O. C.E. Registration & Medical Information Form Camper’s first name:__________ Camper’s last name:__________ Gender:_____ Birth date:__________ Age at time of camp:_____ Grade entering:_____ School, if applicable:____________________ Parent #1 first name:__________ Parent #1 last name:__________ Parent #2 first name:__________ Parent #2 last name:__________ Home address:______________________________ City:_______________ State:_____ Zip:__________ Home phone #:__________ Other #:__________ Parent #1 cell #:__________ Parent #1 work #:__________ Parent #2 cell #:__________ Parent #2 work #:__________ Parent #1 e-mail:______________________________ Parent #2 e-mail:______________________________ Emergency contact:____________________ Relationship to camper:_______________ Emergency phone #1:__________ Emergency phone #2:__________ Has your child been to preschool? Yes No Has your child ever been in an all day camp before? Yes No Please list any food allergies (Note---Nut allergies cannot be accommodated.):_________________________________ ________________________________________________________________________________________________ Does your camper have any non-food allergies or special needs of which we should be aware? Yes No If yes, please explain:________________________________________________________________________ ________________________________________________________________________________________________ Is your child on any medication? Yes No If yes, what is the name and purpose of the medication?_____________________________________________ ________________________________________________________________________________________________ Primary family physician:____________________ Physician’s phone#:__________ Health insurance company:____________________Health insurance policy #:_______________ The following people have permission to pick my child up from camp:_______________________________________ ________________________________________________________________________________________________ Registration fee for Act Like an Animal: $350.00 Payment Methods: See final page of this form. Registration is not accepted until payment is received. This form is due at the time of enrollment. Camper’s name:____________________ T-SHIRT ORDER INFORMATION: Each child will receive one shirt, which is included in the cost of the program. We recommend that you purchase at least one more as your child does need to wear this t-shirt everyday. These shirts are 100% cotton and feature the camp logo printed on the back. 2007 & 2008 t-shirts are acceptable to wear. Please note: “Talk to the Animal” t-shirts (2006 camp) are not acceptable. Shirts will be provided to you on the morning of the first day of camp. Some shirts may be available for purchase during the camp, but supplies will be limited, so advance orders are highly recommended. Camper’s name: Parent’s name: ____ Please enter quantity of t-shirts next to each size: XS, sizes 2-4 _ x $13.00 = S, sizes 6-8 x $13.00 = M, sizes 10-12 x $13.00 = LG, sizes 14-16 x $13.00 = XL, sizes 18-20 x $13.00 = Total cost: Please note: Payment for t-shirts is non-refundable once t-shirts have been ordered. ADDITIONAL TICKETS AND PIZZA PARTY ORDER INFORMATION: As part of your child’s experience, and included in the tuition, your child is given two complimentary tickets (one for them and one for an adult) to see Chitty Chitty Bang Bang at Starlight Theatre on Friday, July 31, 2009. We realize that more than one adult might want to attend, or a friend of your camper might want to tag along. If you would like to order additional tickets for the low cost of $9.00 per ticket, please fill out the information below and fax or mail back to Starlight Theatre. Please call 816.997.1112 for more information. Two tickets for you and your camper are free of charge. $0.00 How many additional tickets would you like to order?_____x $9.00 =__________ How many attendees (including the two free) will attend the pizza party?_____ AFTER CARE AT THE KANSAS CITY ZOO: After Care is available at the Kansas City Zoo for registered camp participants from 3:30 to 5:30 pm for $15.00 per day. After Care participants will be escorted from Starlight Theatre to the Zoo at 3:50pm. You can pick your child up at the Zoo any time between 4:00 and 5:30. Go to the front entrance of the Zoo and follow the After Care sign to your right. Please check all days that you will utilize After Care at The Kansas City Zoo. WEEK ONE WEEK TWO Monday, July 27 Monday, August 3 Tuesday, July 28 Tuesday, August 4 Wednesday, July 29 Wednesday, August 5 Thursday, July 30 Thursday, August 6 Friday, July 31 ***Note: There will be no After Care on Friday, August 7th as it is the final performance/camp day. Total number of days in After Care_____x $15.00/a day =__________ This form is due at the time of enrollment. Camper’s name:____________________ Starlight Theatre/Kansas City Zoo - Consent and Release of Liability Every child, under the age of 18, must have this form signed by a parent or guardian prior to participation in the event. Please fax or hand-deliver this form to: Starlight Theatre Education Department. FAX number: 816-361-6398 Event name: Act Like an Animal Event start date: July 27, 2009 The purpose of this form is to inform you of the above planned activity. Before your child will be allowed to participate in this program, it will be necessary for you to provide your consent. Chaperones, docents and/or instructors will supervise this event. It may be necessary to alter some details of this activity, but efforts will be made to retain normal supervision for the safety and welfare of all participants. Please read the liability release below, fill in your child’s name, sign and date this form. I hereby consent to the participation of my child in an activity at the Kansas City Zoo and at Starlight Theatre. I have read the information materials and have reviewed these with my child. I am aware that activities such as tours, animal viewing, using Zoo transportation, meal functions, crafts and recreation activities may involve risk. I release and forever discharge the Kansas City Zoo, doing business as Friends of the Zoo Kansas City, Inc., and Starlight Theatre, their agents and servants, successors and assigns, directors, instructors, chaperones, trustees, officers, employees and other representatives from any and all damages and causes of actions without limitation for any negligent acts either at law or in equity that result in injury, illness, physical condition or loss sustained by my child during the event. By signing this form, I hereby give permission for any and all medical attention to be administered to my child in the event of accident, injury, sickness, etc. until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. In case I cannot be reached, I give permission for Starlight Theatre and/or the Kansas City Zoo and/or its designates to act on my behalf. I, the undersigned, hereby acknowledge that I have read the foregoing, understand its content and have signed the same as my own free act and deed. I, the undersigned, am aware that my child may be photographed and his/her image may be used in promotional materials for Starlight Theatre and/or the Kansas City Zoo. Printed name of camper:_________________________ Printed name of parent/guardian of camper:_________________________ Signature of parent/guardian of camper:_________________________ Date:__________________________ This form is due at the time of enrollment. Camper’s name:____________________ Total Calculation Sheet for Act Like an Animal Camp Payment Camp enrollment fee: $350.00 *Refunds will not be given after June 23rd. Total for t-shirts: ________ *Payment for t-shirts is non-refundable once t-shirts have been ordered. Total for additional tickets: ________ Total for After Care: ________ Total due to Starlight Theatre: ________ Payment Methods (check one): Visa MasterCard Discover AMX Cash Check If paying with credit card: Credit card #:_________________________ Exp:__________ Name as it appears on the credit card:______________________________ If paying by check: Check #:________ (Please make check payable to Starlight Theatre.) PLEASE READ CAREFULLY: I understand that refunds on the camp enrollment fee of $350.00 will not be given after June 23rd for any reason. I understand that once t-shirts are ordered, payment for t-shirts is non-refundable. I have read carefully all the information in this registration form and will read all the information that is provided to me by Starlight Theatre upon registration. Printed name:______________________________ Signature:______________________________ Date:_______________ Mail form and payment to: Fax form and payment to: Starlight Theatre 816.361.6398 Attn: Amy Reinert 4600 Starlight Road E-mail form and payment to: Kansas City, MO 64132-2032 firstname.lastname@example.org Questions? Call Amy Reinert, Education Coordinator for Starlight Theatre, at 816.997.1112. You may also e-mail her at email@example.com.