May 15, 2014 - Home Phone. Phone__________________________. Home Email ... assume full financial responsibility for any
BYC SUMMER SING I Registration Deadline: May 15, 2014 No tuition – $10 Registration Fee Required Camp: Monday – Friday, June 16-20, 2014 Common Chord Concert: Sunday, June 22, 2014
PERSONAL INFORMATION – fill in both sides and sign on page two Name of Singer ____________________________ Grade in spring ‘14 ______________________ Age ___________________
Birth Date_____________ Sex ____________________________
School _____________________________________ Music Teacher ________________________ ***************************************************************************************** Name of Parent(s)/Guardian(s) ____________________________________________________ Street Address ___________________________________________________________________ City ____________________
State
_____________ Zip Code __________________________
Home Phone __________________________________ Cell Phone__________________________ Home Email _________________________________ Work Phone _________________________ Emergency Contact if parent/guardian not available ______________________________________ Relationship to child ____________________________ Phone ___________________________ ***************************************************************************************** Check all that apply: θ θ θ
1. My child has permission to travel to and from camp by himself/herself. 2. My child will be escorted by his/her parent(s)/guardian(s) to and from camp. 3. My child has permission to be escorted to and from camp by an adult other than his/her parent(s)/guardian(s). If no. 3 above is checked, please provide the name(s) of adults other than Parent(s)/Guardian(s) authorized to pick child up from camp _________________________________________________________________________ _________________________________________________________________________
************************************************************************************* Check one: 1. My child will participate in the Common Chords concert. θ 2. My child will not participate in the Common Chords concert. ************************************************************************************* Each child will receive an official BYC Summer Sing I T-shirt (free). Child’s T-shirt Size: (Circle One) θ
Child M
Child L
Child XL
Adult SM
Adult M
Adult L
*************************************************************************************
Please sign next page… 1
Adult XL
MEDICAL INFORMATION Does your child suffer from any condition or illness that will require special attention or medication? Yes or no? If yes, please describe: _____________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Will your child be bringing any medication with him or her? Yes or No? If yes, please list medications: _____________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Note, members of the BYC Summer Sing I staff are not permitted to give medications to any student. Is your child restricted from participating in any physical activities? Yes or No? If yes, please list: ____ ________________________________________________________________________________
PARENT/GUARDIAN AGREEMENT: I hereby grant permission for my child to participate in all of the activities of the Berks Youth Chorus Summer Sing I, Monday through Friday, June 16 – 20, 2014, including specifically COMMON CHORDS, on Sunday, June 22, 2014. I understand that photos of my child may be taken in the course of camp activities and I grant permission to Berks Youth Chorus to use any and all photos of my child for general distribution. I grant the Berks Youth Chorus all rights to use, reproduce, photograph, record, and otherwise disseminate any aspect of my child’s performance, it being understood that no compensation be made for this use. My son/daughter is physically able to participate in all aspects of the activities (except for those listed above). I hereby release Berks Youth Chorus Summer Sing I, and its employees and those who will be working with the students from any liability in the event of illness, injury or loss occurring to my son/daughter or their personal belongings and will make no claim as a result thereof. I hereby give permission for my son/daughter to be medically treated, as deemed necessary by the staff involved in the Berks Youth Chorus Summer Sing I. I hereby authorize any licensed medical person or facility to treat my son/daughter. I agree to assume full financial responsibility for any medical services provided. ____________ Date __________________________________ Parent/Guardian Signature TO REGISTER: Please complete the registration form and return it with a $10 registration fee by May 15, 2014 to: Berks Youth Chorus 201 Washington Street, Suite 529 Reading, PA 19610 ADDITIONAL INFORMATION: Please contact Dail Richie, Executive Director, Berks Youth Chorus, at 610-898-7664 or
[email protected].
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