Music for the Small and Tall
Around the World in Music and Art - 2015 Summer Camp Registration
Please print legibly!
Participant Information:
Last Name:___________________
First Name:_________________________________
Age:_______________ Allergies/Medical Conditions:_________________________________
Parent/Guardian Information:
Last Name:_____________________
First Name: ________________________________
Street Address:______________________ City:_______________ Zip Code:_______________
Phone Number:
home: ____________________ cell:_____________________________
Do you accept Texts? □ Yes □ No
Email (checked regularly): ________________________________________________________
Emergency Contact (if parent cannot be reached)
Last Name:__________________________ First Name:_______________________________
Phone Number: home:___________________ cell:____________________________________
Relationship to Participant: _______________________________________________________
Water and Small Snack Item
Parents/guardians are responsible for providing their child with drinking water and a snack item
for each day of the camp.
Permission and Release Consent
I give permission for my child to be photographed or videotaped for publicity purposes.
□ I agree
□ I do not agree
I release Ewa Wilczynski and Delpha Hall, Thatcher Mansion Center for the Arts and its officers
and employees, and the Nora Eccles Harrison Museum of Art and its officers and employees
from any liability or expense with respect to claims for injuries, damages, and expenses sustained
by me or my child. I authorize Ewa Wilczynski, Delpha Hall, Thatcher Mansion Center for the
Arts employees and Nora Eccles Harrison Museum of Art employees to notify emergency help in
case of accident or injury to my child while s/he is participating in the Around the World in
Music and Art summer camp. If the above named parent(s) and emergency contact cannot be
reached, consent is hereby given that my child receive medical and/or surgical care as
recommended by a physician or hospital medical personnel.
Signature: ________________________________
Date_______________________
REGISTRATION - PAYMENT
Please mail to: Ewa Wilczynski
81 South 1400 East
Logan, UT 84321-4958
Attn: 2015 Summer Camp
Please print legibly!
Child Last Name:__________________________First Name:______________________
Parent/Guardian Last Name:_________________________First Name:______________
Phone: (_____)___________
Cell Phone (_____)____________________
Email: _________________________________________________________
Note: If parents are registering more than one child, a separate form should be used for each child. No
refunds after July 1, 2015. Full refund, less a $10 registration fee, will be made to written requests by
July 1, 2015. In the unlikely event of camp cancellation due to insufficient numbers, a full refund will be
made. If the camp section is full and you would like to get on the waiting list contact us
http://music4st.weebly.com/contact-us.html
2015 Summer Camp Registration
Around the World in Music and Art
_____ Camp I - July 13 – July 16, Monday - Thursday 9:00 am – 12:00 pm
Ages 4-6, Tuition $60.00
_____ Camp II - July 13 – July 16, Monday - Thursday 1:00 pm – 4:00 pm
Ages 7-8, Tuition $60.00
_____ Camp III - July 20 – July 23, Monday - Thursday 9:00 am – 12:00 pm
Ages 9-11, Tuition $60.00
$______Fee included with this form. Please make check out to Ewa Wilczynski and write 2015
Summer Camp on the memo line. Mail registration form and check to the above address.
Signature: ________________________________
Date_______________________