Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Students entered below will be added to your family's account
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.*
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
Children should dress appropriately for the activities scheduled. We recommends appropriate length shorts and a light weight shirt or top, and some type of athletic shoe or sneaker in order to participate in recreational or athletic activities. Shirts should have a minimum of 1” wide shoulder straps. Clothing that displays drugs, alcohol, tobacco, offensive language, excessive bagginess, or is excessively revealing will not be permitted.
I've read the above and agree.
Personal Belongings
Please put the child’s name on all articles of clothing, snack bags, bags, etc. Children should not bring possession of value with them to any of the camps. Children will be responsible for their belongings.

I've read the above and agree.
Sunscreen/Insect Repellent
Please apply sunscreen and insect repellent prior to the start of each camp session. Children may bring sunscreen and insect repellent but must be able to reapply with staff supervision. Spray or mist sunscreen and/or insect repellent are recommended. Sunscreen and/or insect repellent must be labeled with child’s name. Children may not share these items with others.

I've read the above and agree.
Behavior Management/Discipline Policy
Staff will create a fun and safe environment for participants in the camps. Praise and positive reinforcement are used as effective methods of behavior management. Children who do not respond to these methods or who are destructive to others or to property will be dealt with in a professional, positive, and timely manner to correct the behavior.
I've read the above and agree.
Behavior Management/Discipline Policy
I acknowledge the Discipline Guidelines for Summer Camp and know that I may need to collect my child(ren) if the staff feels he or she is unable to meet the guidelines
I've read the above and agree.
Children must bring a snack and a drink in a non-glass container each day. Snacks should be in a paper, plastic, or reusable bag clearly labeled with the child’s name. Beverages must be clear, or light colored. Brightly colored drinks are prohibited. Snacks must be peanut-free. Please do not send gum or candy. Option to purchase lunch is available, full week or daily.
I've read the above and agree.
Drop off and Pick ups
Drop-off is at 9:00 AM at the lobby of Napa School of Music and Pick up is at 2 PM at the lobby of Napa School of Music.
Children must be signed in and out with one of the Summer Camp staff members.

I've read the above and agree.
Payments are due in full in order to register your child(ren) to attend summer camp.
I've read the above and agree.
No refunds will be given for cancellations or unused services. If you find you need to switch one week for another, you may request this change in writing with one-week prior notice to the Napa School of Music office. All requests will be considered by the Summer Camp Coordinator and we will try our best to accommodate you.
I've read the above and agree.
Electronics Policy
All electronic devices are not allowed during camp. They will be collected at the beginning of each day and returned to them at the end of each day.

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: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*