APPLICATION - Otis Redding Foundation

APPLICATION
June 1–12, 2015, 9 a.m. to 5 p.m. Daily
Camp Contact: Karla Redding-Andrews, 478-742-5737
PLEASE PRINT
First Name_____________________________ MI_____ Last Name __________________________________
Address____________________________________ City_____________
State_____
Zip______________
Camper Email______________________________________ Camper Cell ____________________________
Date of Birth _______________________________ Age____________________________________________
School Attending_____________________________________ Grade Entering Fall 2015_________________
Parent/Guardian Name_______________________________________________________________________
Parent/Guardian Address_____________________________________________________________________
Parent/Guardian Email Address _______________________________________________________________
Home Phone_______________ Work Phone______________
Cell Phone____________________________
Emergency contact/phone other than parent(s) ___________________________________________________
Health Insurance Information__________________________________________________________________
Allergies – please list__________________________________________________________________________
Dietary Needs – please list______________________________________________________________________
T-shirt size Women’s Tee_______ Men’s Tee_______
Do you play an instrument? Name instrument(s) ___________________________________________________
If yes, how long have you been playing? ___________________________________________________________
Are you bringing your own instrument? Y/N______ Please note the camp is not liable for personal instruments.
This form MUST be signed by a Parent or Guardian.
By signing below, I agree that my child will enroll in the Otis Music Camp for the full two weeks,
June 1-12, 2015, and will fully participate in the curriculum. Tuition amount for both weeks: $225.00
Parent’s or Guardian’s Signature ___________________________________________Date________________________
Payment Method: Cash_______ Check_______ VISA _______MC_______AMEX____ Payment Date ___________
Credit Card Number___________________________ Expiration Date________ CCV________ Zip Code ____________
Please return completed application and payment by May 15 to the Otis Redding Foundation, 339 Cotton Avenue, Macon, GA 31201
or email to [email protected]. There will be a $25.00 late fee for applications received after
May 15. Please make checks payable to Otis Music Camp.
All information is kept confidential.