KingsportARTS – KEYPAD Arts Camp Application June 1-5, 2015 -- 8am-5pm for grades 6-12 ►$300 Name:___________________________________________Age:_________________ DOB:___________________ Address:__________________________________________ City, State & Zip:_____________________________ Day-time Telephone # _____________________________ Emergency Contact Tel. #:________________________ Names of Parents/Guardian:______________________________________________________________________ Address (if different than that of camper):____________________________________________________________ E-mail: _______________________________________________________________________________________ Allergies (Camper):_____________________________________________________________________________ Medications:___________________________________________________________________________________ Other medical conditions:________________________________________________________________________ Please list everyone who has permission to pick up your child; we will be checking ID’s: _____________________________________________________________________________________________ Scheduling Conflicts:____________________________________________________________________________ Scheduling conflicts will not change or reduce the price for the week. Given the nature of this camp, campers should wear “work clothes”. Each camper should bring a lunch every day. While Arts Camp is designed to be a fun and creative learning opportunity, it is important that campers respect the time and talents of the instructors and fellow campers. Disruptive behavior will NOT be tolerated. Payment is due with registration by May 15, 2015 and is non-refundable. Registration is confirmed upon receipt of application and payment. Payment and registration can be dropped off 10 a.m. – 3 p.m., Monday-Thursday at KingsportARTS, Suite 216, Renaissance Center or applications can be mailed to: KingsportARTS, 1200 East Center St., Kingsport, TN 37660. Pay with credit card online at KingsportARTS.org. You will be notified through e-mail about class schedule, the closing night event, and other details. □ In the event of an emergency, where reasonable attempts have been made to contact me, I hereby give consent for the administration of any treatment deemed necessary from any hospital reasonably accessible. □ Permission is given to use photos taken during the Summer Arts Camp for publication and/or publicity purposes. In consideration of myself/my child __________________________ (print name) being able to participate in the Summer Arts Camp, I, the undersigned, do hereby release KingsportARTS and the City of Kingsport, their officials, employees, agents, representatives, insurers, sureties and assigns or anyone acting on their behalf, from any and all claims of liability for death, personal injury or property damage of any kind or nature whatsoever, arising out of and in the course of my or my child’s presence, participation in or observation of any KingsportARTS activity. This release extends to all claims of every kind or nature whatsoever, foreseen or unforeseen, known or unknown. Parent/guardian signature__________________________________ Date__________________________