Musical Theater Camp 2023 Registration for Clancy Doherty

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Instructions: Fill out this form and click REGISTER. You will receive an email confirmation shortly after your submission is received and payment has been successfully completed.

"*" indicates required fields

Camper Name*

First Last

Parent/Guardian Name*

First Last

Camper's Grade in 2023–2024 School Year*

Select the grade the student will be ENTERING in fall 2023. Please note that the minimum grade requirement is entering kindergarten.

Please Note

ALL SESSIONS for grades K and 1 are full. To be placed on a waiting list, email alexisc@elefantemusic.com.

We are also offering our Broadway Beginners Camp in late August, for ages 4–6. Click here for more information and to register.

T-Shirt Size*

Musical Theater campers receive a free t-shirt! Please select the student’s size below. Sizes tend to run large.

Camper's Age on July 1, 2023*

Camper's Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone Number*

Email*

Emergency Contacts

Emergency Contact #1 Name*

First Last

Relation to camper*

Emergency Contact #1 Phone Number*

Emergency Contact #2 Name*

First Last

Relation to camper*

Emergency Contact #2 Phone Number*

Allergy/Medical Disclosure

Does your child have an allergy that requires the use of an Epi Pen?*

Yes

My 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, emotional, or special needs you would like us to be aware of:

Camp Selection

Musical Theater Camp 2023

Select Your Session(s)*

Note: Registration is open for Session 2 only. Session 3 is full. To be put on a waitlist for Session 3, please email alexisc@elefantemusic.com

Session 2 July 24 to August 4

Hidden

Select Your Session(s)*

Session 2 July 24 to August 4

Discount

$0.00

Agreements

May we use photographic images and sound bytes of your child for promotional material?*

Yes

How did you hear about us?

Previous attendee

Friend or family member

Internet search

Social media

elefantemusic.com

Other

Payment

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Total

You authorize your card to be charged for this amount:

Click REGISTER ONLY ONCE and DO NOT refresh your page or click the Back button.

If you click REGISTER and receive an error message, email alexisc@elefantemusic.com (rather than registering again, as in many cases we will still receive your registration).