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Mini Mushu Camp Registration

[05/11/2018]

Mini Mushu Camp

Ages 3 years – 7 years

Camp Dates:

            July 16-18, 2018 7:00pm – 7:30pm

            Dress Rehearsal: July 18, 2018

            Performances: July 19, 20,  and 21, 2018  call time TBA

Cost:

            $40.00 includes show shirt and one adult show ticket

            Participants may be asked to provide items from home such as pants, shoes, socks, etc.

 

Registration and Payment due by June 5, 2018. 

            Late registration may be accepted but the show shirt may be forfeited.

 

Location:

            Liberty Center Association for the Arts, Inc.

            111 W. 5th Street

            Sedalia, MO 65301

            660-827-3228

 

Participant’s Name: _________________________________________________

 

Parent/Guardian Name(s): ___________________________________________

 

Address: __________________________________________________________

 

Phone Number: ____________________________________________________

 

Email: ____________________________________________________________

 

Participant’s Shirt Size:  Please choose carefully.  The LCAA cannot exchange shirts or issue refunds.

____ Youth Extra Small

____ Youth Small

____ Youth Medium

____ Youth Large

 

Enrollment in Mini Mushu Camp authorizes the Liberty Center Association for the Arts, Inc. to use photographs or videos of my child with or without his/her name in any medium the aforementioned organization sees fit for the purposes of advertising, display, audiovisual, exhibition, or editorial use.

 

Parent/Guardian Signature: _______________________________________________

Date: __________________________________________________________________

 

Thank you for your interest in the theatre arts!   For more information, please contact:                            

Courtney Wilken, Program Director at (660) 827-3228 or via email Courtney@lcaasedalia.com

 

 

 

 

LCAA Junior Theatre Arts Participant Information Sheet

 

Participant's Name______________________________________________________________________

Date of birth __________________________________________________________________________

Home Address_________________________________________________________________________

Parent(s)/Guardian(s)____________________________________________________________________

Primary Phone _________________________________________________________________________

Cell Phone Parent/Guardian___________________
Work Phone Parent/Guardian________________________

Cell Phone Parent/Guardian___________________
Work Phone Parent/Guardian________________________

 

Permission to Pick-up

Who will be the primary person to transport the participant to and from rehearsals and performances?

Name _______________________________________________________________________________

Phone_______________________________________________________________________

Relationship to participant_________________________________________________________________

List any and all people who have permission to pick up and transport your child:

Name__________________________________________________Phone_________________________

Name__________________________________________________Phone_________________________

Name__________________________________________________Phone_________________________

Name__________________________________________________Phone_________________________

 

Emergency Contact

In the event of an emergency and the parent/guardian cannot be reached, contact:

Name_______________________________________________________________________________

Phone_______________________________________________________________________________

Relationship to participant_________________________________________________________________

 

If the above contact cannot be reached, contact:

Name_______________________________________________________________________________

Phone_______________________________________________________________________________

Relationship to participant_________________________________________________________________

 

Does the participant have any special learning or behavioral needs we need to be aware of to ensure he/she has successful participation in our program?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

 

 

AUTHORIZATION FOR EMERGENCY CARE

            I, hereby, give permission to a physician or dentist selected by the personnel entrusted with the care of my child to order x-rays, routine tests, and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the personnel entrusted with the care of my child to hospitalize, secure proper treatment for, and to order injection and /or anesthesia and/or surgery for my child as named above. 

 

____________________________________________________________________________________

 (Signature of Parent or Legal Guardian)                                                             (Date)

 

 

 

 

 

MEDICAL INFORMATION

 

Child’s Name: _____________________________________________________________________________

 

Family Physician_________________________________________Phone______________________________

Family Dentist___________________________________________Phone______________________________

Family Insurance Company___________________________________________________________________

Policy Number _______________________________________Group Number__________________________

 

 

Immunizations:     Date of last Tetanus shot/booster_____________________               

 

PAST MEDICAL HISTORY

(Check and give appropriate information)

___Asthma     ___Sinusitis     ___Bronchitis     ___Kidney Trouble     ___Heart Trouble     ___Diabetes

___Dizziness     ___Stomach upset     ___Hay Fever     ___Other ____________________

 

Any other significant information or history: __________________________________________________________________________________________

__________________________________________________________________________________________

 

ALLERGIES:  Food: ______________________________________________________

(List type)    
Penicillin or other drug: __________________________________________

                     Insect stings/bites: _____________________________________________

                     Poison Sumac, Oak or Ivy: _______________________________________

 

Previous operations or serious illness: ___________________________________________________________

__________________________________________________________________________________________Any current medications: _____________________________________________________________________

__________________________________________________________________________________________

Special Diet: _______________________________________________________________________________

 

           



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