Fine Arts Camp Registration

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Dates: July 29 - August 2, 2024
Grades: 2nd - 8th
Time: 8:30 am - 4:00 pm
Location: Southeast Church of the Nazarene

Email *

WELCOME TO ACC'S FINE ARTS CAMP

Child's Name *

Phone Number *

Full Mailing Address (including zip code) *

Child's Email Address (if applicable)

Birthday *

YYYY

Current School *

Grade Level in the Fall

Pronoun *

She/Her

He/Him

They/Them

T-shirt size *

Youth XS

Youth S

Youth M

Youth L

Youth XL

Adult XS

Adult S

Adult M

Adult L

Adult XL

Adult XXL

Lives with *

Mother

Father

Both

Other:

County

Race (for grant purposes)

White

Black

Asian

Hispanic

Bi-racial

Other

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Father's Name

Father's Email Address

Father's Phone Number

Mother's Name

Mothers' Email Address

Mother's Phone Number

List persons authorized to pick up your child, their name, and phone number (if not applicable, N/A) *

Emergency Information: If parents/guardians cannot be reached, please notify (two individuals) *

Physician's Name and Phone Number *

Preferred Hospital Name and Phone Number *

Health Insurance Company Name and Group or ID # *

List all known allergies (if not applicable, N/A) *

Please list any special health problems (including allergies) and/or all medications currently being used (if not applicable, N/A) *

Medical Release: In the unlikely event that my child becomes ill or is injured and I or the authorized physician named above cannot be immediately contacted at the time of the emergency, and if in the judgment of the staff of the ACC immediate observation and/or treatment is necessary, I hereby authorize and direct the staff of the ACC to send my child (properly accompanied) to the hospital or physician most easily accessible. Further, I release the ACC and their employees and agents from all claims in connection therewith. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. Please sign and date below. *

If the child lives with a person other than his/her mother or father, please provide the name, phone number, and relationship of the person(s) with whom the child resides.

Please tell us how you heard about our Fine Arts Summer Camp. *

Friend

Current ACC Chorister

ACC's Facebook Page

ACC's Website

Teacher

Other:

Send me a copy of my responses.

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