Summer Theater Camp Registration 2024 - Grades 3-5
Thank you for your interest in summer camp at Piedmont Arts! Please complete the following form and submit payment to reserve your spot! If you are registering more than one child, please complete the registration form for each child. 

July 22-26 - 1pm-5pm - Grades 3-5
**Please note, grade is based on child's current grade level. 

If you have questions, please call Piedmont Arts (276-632-3221) or email Christiana Jarrett, Education Coordinator (cjarrett@piedmontarts.org). 
Email *
Participant's Full Name: 
 *
Participant's Preferred Name:  *
Participant's Current Grade Level:  *
Parent/Guardian Name:  *
Mailing Address (city, state, zip code): *
Parent/Guardian Phone Number:  *
Parent/Guardian Email:  *
What is the best way to contact you?  *
Please list any allergies or health concerns we should be aware of:  *
Please list any additional concerns or needs:  *
Emergency Contact #1 Name:  *
Emergency Contact #1 Phone Number:  *
Emergency Contact #2 Name:  *
Emergency Contact #2 Phone Number:  *
I give permission to staff to provide basic first aid (e.g. band-aids, cold pack, etc.) to the participant if needed. *
I give permission to Piedmont Arts to seek emergency medical care for the participant if needed.
*

I give permission to Piedmont Arts, the right to take photographs of the above named minor in connection with the art camp or workshop.  I authorize Piedmont Arts, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Piedmont Arts may use such photographs of the participant with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. 


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