Musical Theater Camp Session 3 Registration Wait List Openings 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. Select23456789101112T-Shirt Size*Musical Theater campers receive a free t-shirt! Please select the student’s size below. Sizes tend to run large.SelectYouth XSYouth SYouth MYouth LYouth XLAdult SAdult MAdult LAdult XLAdult XXLCamper's Age on July 1, 2023* Camper's Date of Birth* Month Day Year Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone Number*Email* Emergency ContactsEmergency 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 DisclosureDoes your child have an allergy that requires the use of an Epi Pen?* Yes No 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 SelectionMusical Theater Camp 2023Selected Session* Session 3 August 7 to August 18 AgreementsConsent 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 to the medical emergency policy.Pingry's lunch policy agreement*Due to allergy concerns, The Pingry School requires all Elefante campers to participate in Pingry’s lunch program. Pingry charges $20 per day for their lunch program ($200 for a full 2-week session). Payment for the $200 lunch fee is included in the total session price of $1,025. The lunch payment collected by Elefante will be paid to Pingry. I agree to Pingry’s lunch policy.Cancellation policy and fees*You may cancel your registration. However, the following fees apply and will be deducted from your refund: • Cancel on or before 6/10/23: no deduction • Cancel 6/11/23 through 6/19/23: $50 deduction • Cancel 6/20/23 through 6/26/23 : $75 deduction • Cancel 6/27/23 through 7/3/23: $100 deduction • Cancel 7/4/23 or later: $125 fee I agree to the cancellation policy and applicable fees.Code of Conduct and Core Values*Elefante Music and School for the Performing Arts maintains a high standard of educational excellence. As such, we require that all students attending lessons, classes, camps, or similar activities read and adhere to our Code of Conduct and Core Values, which can be viewed VIA THIS LINK. After reading, hit the back arrow(s) to return to this form. I have read and agree that my child will comply with Elefante Music’s Code of Conduct and Core Values.May we use photographic images and sound bytes of your child for promotional material?* Yes No How did you hear about us? Previous attendee Friend or family member Internet search Social media elefantemusic.com Other PaymentCredit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name TotalYou 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 firstname.lastname@example.org (rather than registering again, as in many cases we will still receive your registration).