Musical Theater Camp 2021 Registration Instructions: Fill out this form and click SUBMIT. You will receive an email confirmation shortly after your submission is received and payment has been successfully completed. Student Name* First Last Parent/Guardian Name* First Last Student Age on July 1, 2021*Student Date of Birth* MM DD YYYY Grade in 2021–2022 School Year*Select the grade the student will be ENTERING in fall 2021. Please note that the minimum grade requirement is entering kindergarten. Select Student's GradeKindergarten (minimum grade requirement)123456789101112Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home PhoneCell Phone*Will be used as primary phone number.Email* Emergency Contact Name* First Last Emergency Contact Phone Number*Previous instrumental music, voice, acting, or dance experience. If any, please indicate and for how long:Does your child have an allergy that requires the use of an Epi Pen?*YesNoMy child is allergic to:*Check all that apply from the 3 choices below* An Epinephrine injector has been prescribed for my child. A device designed for self-administered asthma treatment (not necessarily Epinephrine) has been prescribed for my child. My child has received adequate training on how and when to use an Epinephrine injector and can use it properly in case of an emergency. He or she will carry Epinephrine injectors at all times. Authorization to allow self-administration. Select one of the options (required).*I hereby authorize...I hereby DO NOT authorize......my son/daughter to self-administer the epinephrine auto-injector (Epi-Pen® or similar devices designed for self-administered asthma treatment). I agree to indemnify and hold harmless Elefante Music and School of Performing Arts and any of its staff, volunteers, or agents from lawsuit, claim, loss or expense, demand, or action against them, including reasonable attorneys’ fees, suffered by any of the foregoing indemnities and arising out of a claim related directly or indirectly to my son/daughter’s self-administration of or failure to self-administer the above referenced epinephrine auto-injector. Authorization to allow staff to administer auto-injector. Select one of the options (required).*I hereby authorize...I hereby DO NOT authorize......Elefante Music and School of Performing Arts staff and volunteers to administer an Epinephrine injector (Epi-Pen® or similar devices designed for self-administered asthma treatment) to my child if he or she appears to have had significant exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless Elefante Music and School of Performing Arts and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them, including reasonable attorneys’ fees, suffered by any of the foregoing indemnities and arising out of a claim related directly or indirectly to administering or failing to administer the Epinephrine injector. I am aware that the injection will likely be administered by a staff member or volunteer who is not a healthcare professional. Any medical or emotional issues you would like us to be aware of:Consent to Treat in the Event of a Medical Emergency*If you cannot be reached in an emergency, do you give permission to the proper medical staff to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child, understand the information on this form will be shared on a "need to know" basis with Elefante Music staff?I agree.T-Shirt Size*Musical Theater campers receive a free t-shirt! Please select the student's size below. Sizes tend to run large.Please select sizeYouth XSYouth SYouth MYouth LYouth XLAdult SAdult MAdult LAdult XLAdult XXLMay we use photographic images and sound bytes of your child for promotional material?* Yes No How did you hear about us?Musical Theater Camp (Base)Camp Session Selection*Select the session(s) for which you wish to register. All tuition fees are fully refundable prior to the start of each session. To receive the $100 discount, make sure you CHECK ALL 3 SESSIONS (discount will automatically apply). Session 1: July 12–July 23 Session 2: July 26–August 6 Session 3: August 9–August 20 Discount $0.00 COVID-19 Testing Fee(s) The Pingry School will require all campers to participate in weekly, pooled saliva testing designed to identify potential infection with COVID-19. The Pingry School charges $20 per camp week for testing ($40 per two-week session). This fee is in addition to and separate from Elefante camp tuition, and, while collected here, will be paid in full to The Pingry School. By enrolling in Musical Theater Camp, you are giving your consent to weekly saliva testing and payment of the $40 PER SESSION COVID-19 Testing Fee, as automatically added below. PLEASE NOTE: Pingry will test on the Wednesday or Thursday prior to each week, so the camper must be available for testing in the week prior to the session(s) for which you are registering. COVID-19 Testing Fee - Session 1* Price: $40.00 COVID-19 Testing Fee - Session 2* Price: $40.00 COVID-19 Testing Fee - Session 3* Price: $40.00 Payment MethodCredit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Security Code Cardholder Name TotalBy clicking submit, you authorize your card to be charged for this amount: $0.00 Ready to register? Read this first: Click SUBMIT ONLY ONCE and DO NOT refresh your page or click the Back button. If you click SUBMIT but receive an error message, email firstname.lastname@example.org (rather than registering again, as in many cases we will still receive your registration). THANK YOU!