Spring Registration Form

Breakthrough Spring Break Camp Registration Form
And Student Emergency Contact Form


Student's Full Name: ___________________________________________ Male_____ Female_____

Address:____________________________________ City_______________ State____ Zip________

Date of Birth:_________________ Age: _____ Grade: _____ School: __________________________

Mother/Guardian Information:                                                                                     
Home Phone: __________________        Work Phone: _____________________
Cell Phone: ____________________       Email: ___________________________       
Employer: _________________________________________________________       


Father/Guardian Information:
Home Phone: __________________   Work Phone:________________________
Cell Phone: ____________________   Email: _____________________________
Employer: _________________________________________________________


Payment (Cash or Check Only): $100.00 ($50 deposit and $50 on the first day)

I will be attending:
_____ March 19-23, 2012
_____ March 26-30, 2012
 

Pick Up:
The following people are authorized only to pick up this student for checkout. Picture ID will be requested prior to checking out student.

Person #1: ______________________________________ Relationship: _______________________
Person #2: ______________________________________ Relationship: _______________________
Person #3: ______________________________________ Relationship: _______________________
Person #4: ______________________________________ Relationship: _______________________

Please read and sign the following policies and releases:
Camp Refund and Cancellation Policy: Once the student has started the camp, there are no refunds. If your student withdraws before the first day of camp, you will receive a full refund. If the camp is canceled, you will receive a full refund.

Photo Release: I grant the Breakthrough Theatre permission to photograph, record, or otherwise secure images of my child or myself. In addition, I hereby permit the Breakthrough Theatre to use these images and publish in print, electronic, or video format these likenesses. I release all claims against the Breakthrough Theatre with respect to copyright ownership and publication including any claim for compensation related to the use of these materials.

Insurance Agreement: I agree to release, discharge, and hold harmless the Breakthrough Theatre and its staff, of and from any claims, demands or liability of damage arising from the participation of my child in any programs sponsored by the Breakthrough Theatre. In the event my child becomes ill, I authorize the Breakthrough Theatre staff to obtain medical attention for my child at a physician's office or hospital. I understand that every effort will be made to reach me before medical permission is given to treat my child. My child has the following insurance coverage:

Insurance Company: ____________________________________________
Insurance Phone Number: ________________________________________

Group #: _____________________________________________________

In order to assist the Breakthrough Theatre in obtaining care for your child in an emergency, please indicate whether your child has any medical issues, including allergies or special needs.

_____ Yes   _____ No

If yes, please describe in detail:



Parent Signature: ____________________________________    Date: ________________________


Please mail this form and a $50 deposit to:

Wade Hair
3055 Riverbrook Drive
Winter Park, FL 32792