Summer Camp Registration · Black Arts MKE

* are required fields

Youth Information

First Name *

Middle Name

Last Name *

Gender * Male (inclduing transgender men) Female (including transgender women) Prefer to self describe ____________________(non-binary, gender-fluid, agender, please specify) Prefer not to say

Performing Arts Interests (check all that apply) * Dance Music Theatre Musical Theatre Spoken Word Other ____________________

Street Address *

City *

Zip Code *

School Name *

Grade *

Birth Date *

Age *

Parent / Guardian Information

First Name *

Last Name *

Parent 1 Street Address *

Parent 1 City *

Parent 1 Zip Code *

Parent 1 Cell Phone

Parent 1 Work Phone

Parent 1 Email

Parent / Guardian #2

First Name

Last Name

Parent 1 Street Address

Parent 1 City

Parent 1 Zip Code

Parent 1 Cell Phone

Parent 1 Work Phone

Parent 1 Email

Alternate Pick-up / Release

First Name:

Last Name:

Cell Phone

Home Phone

Email Address:

Relation to Youth

Medical / Insurance Information

Policy Number

Health Insurance Provider

Primary Physician

Physician Address

Physician Phone

Hospital Preference

Is your youth allergic to any type of food or medication? Yes No

If yes, please explain

Does your youth require a special diet? Yes No

If yes, explain

Please list any medical problems, including any requiring maintenance medication (i.e. diabetic, asthma, seizures)

Medical Problem

Required Treatment

Should we call paramedics?

Emergency Contact(s)

Emergency Contact 1 Name *

Emergency Contact 1 Phone Number *

Emergency Contact 1 Relationship to Youth *

Emergency Contact 2 Name

Emergency Contact 2 Phone Number

Emergency Contact 2 Relationship to Youth

I understand that I will be notified in the case of a medical emergency involving my youth. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my youth is injured or becomes ill.

Parent / Guardian Initials *

I understand that Black Arts MKE Youth Performing Arts Camp will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

Parent / Guardian Initials *

HOW DID YOU HEAR ABOUT Black Arts MKE Youth P-Arts Summer Camp? * After/School Program Website Attended Previously Social Media Flyer Other

Photography / Photography Release

I hereby give permission for my child to be photographed during the Black Arts MKE Youth P-Arts Summer Camp. I understand the photos/videos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph/video may be used for promotion, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Black Arts MKE Youth P-Arts Summer Camp.

Parent / Guardian Initials *

The Black Arts MKE Youth P-Arts Summer Camp and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. Photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

Parent / Guardian Signature *

Signature Date *