Registration


Event:
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Type*
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
 
Address: *
City: * State: * Zip: *
 
 
Students entered below will be added to your family's account
 
Questions/Options:
Student Name 1, Age & Instrument*
Student Name 2 and Age & Instrument
Student Name 3 and Age & Instrument
Parents or Guardians*
Authorization to Pick up Child(ren) Name and cell numbers of persons (other than the legal guardian or parent) authorized to take child from facility. Identification will be required.
In order to meet the needs of your child, please provide any information regarding any disabilities or special needs.
Allergies: No Known Allergies (checked=yes)
Please list any medications such as inhaler and/or epinephrine Auto-injection (Epi-Pen) for anaphylactic reactions, (you must provide one with training).
Camper is allergic to: Food (Lactose, Peanuts, Nuts, gluten intolerant) Other Medicine The environment (Insect stings, hay fever, etc.) Other
Please explain if apply
I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.*
I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.)
Medical Insurance Information: This camper is covered by family medical/hospital insurance*
Insurance Company and Policy Number*
Subscriber and Insurance Company Phone Number*
This health history is correct and accurately reflects the health status of the camper to whom it pertains.*
The person described has permission to participate in all camp activities except as noted by me and/or an examining physician.*
If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child.*
I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child in emergency situation.*
Parent/Guardian*
Date:*
Relationship to Camper*
If for religious or other reasons you cannot sign this, contact Napa School of Music for a legal waiver which must be signed for attendance. (checked=yes)
 
Additional Information:
 
Dress Code
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I've read the above and agree.
 
Personal Belongings
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I've read the above and agree.
 
Sunscreen/Insect Repellent
  (Show-Hide Details)
I've read the above and agree.
 
Behavior Management/Discipline Policy
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I've read the above and agree.
 
Behavior Management/Discipline Policy
  (Show-Hide Details)
I've read the above and agree.
 
Nutrition/Snacks
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I've read the above and agree.
 
Drop off and Pick ups
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I've read the above and agree.
 
Payments
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I've read the above and agree.
 
Cancellation
  (Show-Hide Details)
I've read the above and agree.
 
Electronics Policy
  (Show-Hide Details)
I've read the above and agree.
 
Enter your Full Name: *   
 
Other Questions/Comments:
 
Credit Card Verification:
   
Card Number: *  
Name as it appears on card: *
Nickname:
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*