to a registration form.

FOR OFFICE USE ONLY Payment Type: Cash ____ Credit ____ Check No. __________ Scholarship _________ Email Confirmation Sent ____ Jerry Maloy, Artistic Director Amanda Short, Musical Director Niswonger Performing A rts Center PO Box 727 Greeneville, TN 37744 Office: 423-­‐638-­‐1328 Fax: 423-­‐638-­‐1346 2016 Summer Theatrical Day Camp Registration Form
Parent Information: Parent Name: ______________________________________________________________________________________ Address: ______________________________________________________________________________________ City/State/Zip: ______________________________________________________________________________________ Phone: Home: _________________________________________________________________________________ Work: _________________________________________________________________________________ Cell: ___________________________________________________________________________________ Email Address: ______________________________________________________________________________________ Emergency Contact 1: Name: __________________________________________________________________________ Phone: __________________________________________________________________________ Emergency Contact 2: Name: __________________________________________________________________________ Phone: __________________________________________________________________________ Student Information: Name: ____________________________________________________________________________________________ Date of Birth: ________________________ Grade (completed): ___________________ Gender ____________________ T-­‐Shirt Size: ☐Youth S ☐Youth M ☐Youth L ☐Youth XL ☐Adult S ☐Adult M ☐Adult L th
Camp Selection: ☐July 11-­‐15 Snow White & The Seven Dwarfs Ages: K-­‐4 Grade The Wizard of Oz Ages: 5 – 12 Grade ☐July 18-­‐22 th
th Medical Information: Please use the space below to list any medical conditions, prescriptions, allergies, or special needs. Medical information provided will only be shared with NPAC staff as necessary. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Student Information: (Student Two) Name: ____________________________________________________________________________________________ Date of Birth: ________________________ Grade (completed): ___________________ Gender ____________________ T-­‐Shirt Size: ☐Youth S ☐Youth M ☐Youth L ☐Youth XL ☐Adult S ☐Adult M ☐Adult L th
Camp Selection: ☐July 11-­‐15 Snow White & The Seven Dwarfs Ages: K-­‐4 Grade The Wizard of Oz Ages: 5 – 12 Grade ☐July 18-­‐22 th
th Medical Information: Please use the space below to list any medical conditions, prescriptions, allergies, or special needs. Medical information provided will only be shared with NPAC staff as necessary. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Release Form: (A signature is required in order to process your registration.) I agree to release and discharge Niswonger Performing Arts Center and its directors, employees, and staff of and from any claims, demands, or liability of damage arising from the participation of my student in any classes or programs sponsored by Niswonger Performing Arts Center. In addition, I understand pictures of classes may be taken and used for publicity or promotional purposes. I consent to any medical treatment necessary for my student in an emergency and acknowledge that any expenses incurred are my sole responsibility and will not be paid for by Niswonger Performing Arts Center. Parent/Guardian Signature: ___________________________________________________________________________ Date: _________________________________________________________________________ Camp Payment: Student 1 Tuition: $ ___________________________ Student 2 Tuition: $ ___________________________ TUITION: st
$250 1 student nd
$225 2 student (same session) Total Payment Enclosed: $ ___________________________ Payment Form: ☐ Cash: Present this form and pay in person at the NPAC box office during regular business hours. ☐ Check: Present or mail this form with your check to: NPAC, PO Box 727, Greeneville, TN 37744 ☐ Credit Card: Card Type: ☐Visa ☐Mastercard ☐American Express ☐Discover Card Number: ______________________________________________________________________________________ Expiration Date: ____________________ Billing Zip Code: ______________ Security Code: _________________ (3 digits shown on back of card, 4 digits shown on front of card for American Express) For credit card payments present this form in person, fax to 4 23-­‐638-­‐1346, or scan/email to [email protected]