Camp Music Circus 2023 Application Camp Music Circus Application "*" indicates required fields Child's InformationNAME* First Last NICKNAME GRADE IN SCHOOL*Please enter a number from 3 to 8.AGE*Please enter a number from 9 to 12.DATE OF BIRTH* MM slash DD slash YYYY GENDER IDENTITY/PRONOUNS Please list any medical conditions, chronic ailments, allergic reactions, disabilities or school IEP accommodations that we should be aware of:CAMP T-SHIRT SIZE*Youth SmallYouth MediumYouth LargeUnisex SmallUnisex MediumUnisex LargeUnisex X-LargeParent/Guardian Contact InformationNAME (Parent/Guardian 1)* First Last RELATIONSHIP TO CHILD* ADDRESS (Parent/Guardian 1)* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code MOBILE PHONE (Parent/Guardian 1)*WORK PHONE (Parent/Guardian 1)Is this person allowed to pick up/drop off the child? Yes* Yes No EMAIL (Parent/Guardian 1)* NAME (Parent/Guardian 2) First Last RELATIONSHIP TO CHILD ADDRESS (Parent/Guardian 2) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code MOBILE PHONE (Parent/Guardian 2)WORK PHONE (Parent/Guardian 2)Is this person allowed to pick up/drop off the child? Yes No EMAIL (Parent/Guardian 2) Emergency InformationOther than parent/guardian, please list the next person you’d like us to contact in case of an emergency. EMERGENCY CONTACT* First Last RELATIONSHIP TO CHILD* EMERGENCY CONTACT MOBILE PHONE*Authorized PickupOther than parent/guardian, please list who else has permission to pickup your child from camp.CONTACT INFORMATION Name Relationship to Child Phone Number CONTACT INFORMATION Name Relationship to Child Phone Number CONTACT INFORMATION Name Relationship to Child Phone Number CONTACT INFORMATION Name Relationship to Child Phone Number StatementEnter a one-paragraph statement (4-6 sentences) describing any background the applicant has in theatre, music, or dance, and/or their hobbies.*ScholarshipsA limited number of scholarships are available for Camp Music Circus applicants. Please indicate below whether you are interested in applying by May 1, 2022.SCHOLARSHIPS I would like to apply for a Camp Music Circus Scholarship STATEMENT: Please provide a brief statement from a parent or guardian defining the circumstances of the Application request and why their child would benefit from the experience of attending Camp Music Circus.ReleasesRelease of Liability* – My child has permission to attend Camp Music Circus (July 17 to July 28, 2023). I understand that I am releasing Broadway Sacramento and the Camp Music Circus instructors and volunteers from any and all liabilities incurred while at the program. Authorization to Reproduce Physical Likeness* – I expressly grant to Broadway Sacramento and to its employees and agents the right to photograph, film, or videotape my child and to use the resulting images in media promoting Broadway Sacramento and its activities. I further grant the right to record and reproduce my child’s voice and all instrumental, musical, and other sound effects produced by my child. I hereby certify and represent that I have read the foregoing and fully understand the meaning and effect thereof. Vaccination RequiredAs we move forward in understanding and complying with federal, state, and local laws, orders, and recommendations, and in Broadway Sacramento’s continued efforts to promote the health and well-being of our employees, their families, visitors, and others, Broadway Sacramento has implemented certain safety protocols. All Camp Music Circus participants must be fully vaccinated (two or more doses) at least two weeks prior to the start of Camp Music Circus, by July 3rd, 2023.VACCINATION INFORMATION* My child is fully vaccinated. My child is not fully vaccinated If your child is not fully vaccinated, please provide proof of medical exemption.Accepted file types: jpg, png, pdf, Max. file size: 50 MB.DATE OF FINAL DOSE:* MM slash DD slash YYYY How did you hear about Camp Music Circus? Email from Broadway Sacramento Broadway Sacramento website Friend/Word of Mouth Social Media (Facebook, Instagram, etc.) Other HiddenBroadway Sacramento reserves the right to exercise discretion in accepting applicants. Enrollment is on a first-come, first-served basis and will end when we reach program capacity.CAPTCHAPost BodyEmailThis field is for validation purposes and should be left unchanged.
