Musical Theater Camp 2024 Registration for Libby Kasserman

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 2024–2025 School Year*

Select the grade the student will be ENTERING in fall 2024. Please note that the minimum grade requirement is entering kindergarten.

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, 2024*

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 or a device designed for self-administered asthma treatment (not necessarily Epinephrine)?*

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 their device, and can use it properly in case of an emergency.

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

Camper Pick-Up*

In the space below, please list the names of all persons who have permission to pick up your camper(s). Please include first and last name, and relationship to the camper.

"Keep-Togethers"

In the space below, please note if there are any other campers you would like your child to be grouped with. We cannot guarantee they will be together, however we will do our best to accommodate you. We request that you please provide this information now, as we may not be able to change assignments when the camp start-time approaches.

Camp Selection

Musical Theater Camp 2024

Select Current Payment Installment*

Select the appropriate payment installment from the list below. The prices listed in each installment reflect the 30% Pingry Staff discount for Session 2 (July 15 – July 26).

First Payment Installment, Due 4/1/24

Second Payment Installment, Due 5/1/24

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).