Franklin Community Players and

Franklin County Recreation Department present:

Summer Drama Camp

I understand that my child is registering in a drama program and that the possibility of injury does exist. My approval for my child to participate in this program is hereby given. I do assume all risks and hazard incidental to participation: including transportation to and from activities. I do hereby absolve, waive, release, and agree to hold harmless the Franklin Community Players, the Franklin County Recreation Department, the contractors, the instructors, volunteers, participants and the staff for any claim arising from injury, with the exception of negligence. I give my permission for the appropriate personnel and volunteer to seek qualified medical treatment for my child in the event of a medical emergency in my absence. I assume all responsibility for insurance on my child. I understand that accident insurance is available for an additional fee of $8.50.

I wish to purchase the offered insurance: _____ Yes or _____ No Please complete the attached insurance form!

Does your child have any medical/physical conditions that we should be aware of? (including: allergies, asthma, etc)

_____ Yes or _____ No

If you answered yes to the above question, please give a complete description of their condition on the back of this form.

If you answered yes to the above question, has your child been cleared by a doctor to participate in this program?__ Yes__ No

Participant’s Name: ___________________________________ Age: __________________

t-shirt size (youth-s, y-m, y-l, y-xl, adult-m, a-l, a-xl)______________________

Address: __________________________________________________________

City: ________________________ State: ________ Zip: ______ fall 08 Grade:_________

Home Phone: _________________ Cell Phone: ___________________

Mother’s Name: ___________________ Work Phone: ________________

Father’s Name: _____________________ Work Phone: ________________

Parent’s e-mail address: _________________________________________________

As we communicate primarily by e-mail, please ‘allow’ e-mail from fcplayers@windstream.net.

Emergency Contact: ___________________________ Phone# :_________________________

Doctor’s Name: __________________________ Phone #: _____________________________

Insurer: _________________________________ Policy #: ________________________________

Student’s interests (acting, singing, art, writing, tennis, make-up, etc)_____________________

Only the following people are authorized to pick up my child(ren):_________________________

_______________________________________________________________________________

Camp will be held July 14 - 18, 2008; 8 am - 12 pm. Monday – Thursday, all activities will take place at the Franklin County Recreation Department-Rocky Ford Bldy. Friday, all activities will take place at the FCHS Fine Arts Auditorium until 2 pm, with a 6:30 pm recital. Camp registration fee of $40 will cover camp, a t-shirt, and the final recital. Siblings’ fees will be $5 less per sibling; 1^stchild $40, 2^ndchild $35, 3^rd child $30. No refunds after 6/15 deadline. Name/age/grade of siblings may be included on the back of one family form.

I have read and understand the above statements and give my approval under the conditions provided.

___________________________________ _________________

Parent or Guardian Signature Date

Office Use Only: Payment Received: $______ Cash____ Check #_______ Date _______ Initials______