186x Filetype DOCX File size 0.03 MB Source: www.riverparkcenter.org
2022 ROCK CAMP REGISTRATION FORM Camper Information Additional Info Last Name: ______________________________ Do you own an instrument?____ Which ones? _______ _____________________________________________ First Name: ______________________________ Do you have any experience with playing an Grade Completed: ______ instrument?_____ Please describe_________________ Birthdate: ____ /_____ /_____ (MM/DD/YY) _____________________________________________ Address: _________________________________ Circle the instrument(s) that interest you: Guitar Bass Drums City: _______________ Zip Code:_____________ Dominant hand: Right Lef Home Phone #:____________________________ Would a guardian be willing to volunteer during camp? Parent/Guardian Daytime Contact Information Shirt Size (circle): YS / YM / YL / YXL Guardian (1) Name: ________________________ AS / AM / AL / AXL Day Time Phone #: ________________________ Pricing Email Address: ____________________________ Rock Camp Guardian (2) Name: ________________________ 5 Day Camp May 23rd–27th, 2022 9am–12pm & 1pm-4pm Daytime Phone #: __________________________ Camper(s):________ x $150 = _________________________ ___Check enclosed ___Cash/Credit paid at box office Alternate Emergency Contact Information Please make checks payable to: RiverPark Center Name: __________________________________ 101 Daviess Street, Owensboro, KY 42303 Phone #:_________________________________ Waiver Relation to Camper: ________________________ I certify that all information given above is correct. I hereby List the names of any adults/siblings who have your give permission to have staff arrange any emergency medical care, including hospitalization if necessary. In all instances, permission to sign your child out. (Any names not on attempts will be made to contact the guardian first. The this list will be unable to sign the camper out without a participant is responsible for his/her medical coverage. handwritten note.) I hereby release RiverPark Center and all teaching artists from ______________________________________________ all claims arising from participation in any activity associated ______________________________________________ with this Day Camp. ___________________________________________ I authorize the use of any photos taken during the camp for future non-profit promotional purposes. Medical Information _________________________________ ____________ Medical Issues (including allergies)? Y / N (Guardian’s Signature) (Date) If yes, please explain: ______________________ For more information, please contact: ________________________________________ Matt Waller, mwaller@riverparkcenter.org Or call the box office: (270) 687-2770
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