Popcorn Hat Players Summer Camp Registration


Student Name *
Student Name
Birthdate *
Birthdate
Address *
Address
Parent/Guardian Name
Parent/Guardian Name
Address *
Address
Home Phone *
Home Phone
Cell Phone *
Cell Phone
Work Phone
Work Phone
Parent/ Guardian 2
Parent/ Guardian 2
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Please read carefully: *
I give permission for still or video pictures of my child to be used by Gamut Theatre Group for promotional purposes I hereby give my permission for my child named above to attend the session for which he/she is registering.
Method of payment *
Medical Information
Physicians Phone Number *
Physicians Phone Number
Date of Last Physical *
Date of Last Physical
Please check all that apply and explain as necessary: *
The health history and other information requested are accurate to the best of my knowledge The child herein described has permission to engage in all prescribed activities except as noted In the event I cannot be reached in an emergeny I hereby give permission to the Director to secure proper treatment *