Registration Medical Information Form

							                                                                                      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                                                 amy.reinert@kcstarlight.com

         Questions? Call Amy Reinert, Education Coordinator for Starlight Theatre, at 816.997.1112.
                         You may also e-mail her at amy.reinert@kcstarlight.com.