Camp Brook Registration Form

Camper's Name *

First Name Last Name

Birth Date *

Month Day Year

Grade *

Address *

Street Address

Street Address Line 2

City State

Zip Code

Parent/Guardian Information

Name *

First Name Last Name

Home Number *

Area Code Phone Number

Cell Number *

Area Code Phone Number

E-mail *

Emergency Information

Phone Number *

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does the Camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

AGREEMENT, RELEASE FROM LIABILITY, WAIVER OF CLAIMS & ASSUMPTION OF RISK

I agree to pay all participation fees. I, on behalf of myself, my heirs, executors, agents, assigns, and representatives, hereby indemnify, release and forever hold harmless Brook Arts Center (BAC), a not-for-profit organization, as well as its directors, employees and instructors, from any and all claims of liability arising from any accident, personal injury, death, or property loss or damage sustained by my child/myself/the minor child for whom I am a legal guardian, while that person is participating in activities connected with BAC, including classes, rehearsals, and performances.

I consent to have my minor child, for whom I am a legal guardian, participate in program and activities offered by BAC and I accept full responsibility for providing adequate health and accident insurance coverage for the protection of all of the following who participate in these programs/activities. by submitting this statement, I declare that the aforesaid participant is in good health, with no physical conditions that might prevent his/her participation in all activities and performance connected with Camp Brook Summer Theater Camp.

By submitting this in my capacity as the legal guardian of a minor child, I also authorize the Brook Arts Center to use photos and videos of the minor child for promotional purposes.

I have carefully read this Agreement, Waiver, Release, & Assumption of Risk and fully understand its contents and agree to the above terms. I understand that this is an assumption of risk and release of liability, and I have agreed to of my own free will.

*FAMILY DISCOUNT PROMOTION IS ONLY APPLICABLE FOR TWO OR MORE FAMILY MEMBERS. THE CODE CAN ONLY BE USED ONCE PER FAMILY. *

CAMP REGISTRATION $ 469.00

EARLY BIRD DISCOUNT $ 419.00

Enter coupon

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

CAMP BROOK