2017 Summer Camp Form

Shakespeare’s Avengers

Location: Goodwood Museum and Gardens
                1600 Miccosukee Rd






Camp Dates:   Middle School: 6/19 - 6/23     Elementary School: 6/26 - 6/30

(* designates required field)

Child's Name*

Choose Week(s)* Middle SchoolElementary

Grade Entering Fall 2017*

School*

Date of Birth*

Gender*

Additional Child's Name

Choose Week(s) Middle SchoolElementary

Grade Entering Fall 2017

School

Date of Birth

Gender

Mailing Address

Parent/Guardian Name*

Parent/Guardian's Phone*

CellHomeWork

Parent/Guardian's Email Address*

Additional Parent/Guardian's Name

Additional Parent/Guardian's Phone

CellHomeWork

Additional Parent/Guardian's Email Address

Emergency Contact's Name

Emergency Contact's Phone

CellHomeWork

Emergency Contact's Email Address

Emergency Contact's Relationship to Camper

Alternate Persons Authorized to Pick Up Camper

Name

Phone

CellHomeWork

Name

Phone

CellHomeWork

Health Information

Medications Taken Regularly

Allergies

Health Insurance Company Name

Health Insurance Company Policy #

Physician's Name

Physician's Phone

Parental Authorization For Emergency Treatment

Should my child become ill or suffer an accident during the time that he/she is in the care of Southern Shakespeare Company, the camp will contact me immediately. In the event that the camp is unable to reach me immediately, I authorize Southern Shakespeare Company to secure medical attention for my child as may be necessary.
YesNo

Parental Authorization For Pictures

Do you give your permission to have your child's picture taken and displayed at Southern Shakespeare Company Summer Camp or on the Southern Shakespeare Company website?
YesNo

What is your child's t-shirt size? Each camper will receive a free Southern Shakespeare Camp t-shirt.
Child 1:
Child 2:

Is there anything special we should know about your child? Can he/she participate in all camp activities?

I am interested in the before-care option (8am - 9am) and/or after-care (3pm – 4pm) for my child for an additional $10/hr.
YesNo