Child's First Name:
Child's Last Name:
Date of Birth	Age:
Gender	Female Male
Home Address:
Street:
City:	State: Zip:
Parent/Guardian Name 1:
Work#:
Home#:
Cell#:
Email:
Parent/Guardian Name 2:
Work#:
Home#:
Cell#:
Email:
Emergency Contact Name:
Emergency Contact #:
Relationship to Family:

Statement of Wellness for Participation and Photo/Video Release:
I verify that my child is to the best of my knowledge free from contagious disease, able to participate fully in the Sugarfoots Performing Arts Camp, fully immunized and is not exempt from immunizations for religious or health reasons, has no other medical illness or condition that prevents full participation in the Camp. In case of a medical emergency and in the event that the parent/guardian/emergency contact cannot be immediately contacted, I hereby give my permission for emergency treatment to be administered to my child. I understand that Sugarfoots does not carry accidental injury insurance on the Camp and/or on said leased facilities. I hereby release Sugarfoots and its heirs, assigns and employees from all liability for any personal injuries, illnesses, loss or damage to property. I agree to assume liability for any expenses incurred in such an emergency (transportation, hospitalization, x-rays, etc.) I also give permission for Sugarfoots to use any photos/video taken during the camp in which myself or my child may appear in. Sugarfoots will be given permission to use these photos/videos in print (on advertisements or marketing materials) or on the Sugarfoots website (www.sugarfoots.com) or other Sugarfoots affiliated or sponsored web sites.
I agree to the terms and conditions of the above Statement of Wellness for Participation and Photo/Video Release.
I am the legal Parent/Guardian for this child.

Date of last DPT/Tetanus immunization (required by law):

SPECIAL MEDICAL CONCERNS
Note: If your child requires a special diet, meals must be provided by parents.

Please use the area above to describe any ALLERGIES, MEDICAL CONDITIONS and/or SPECIAL NEEDS.

Child T-Shirt Size:
S (6-8) M (10-12) L (14-16) XL (18-20)

How did you hear about Sugarfoots?
Mailer Internet Advertisement Word of Mouth Other

Please list any special talents your child may have:

Payment by check or credit card (MC, Visa, Amex, Discover).
Sorry No Refunds!

SUMMER CAMP FEES:
Early Registration Deadline: May 1, 2010
Before April 30, 2010: $250.00 per week
After April 30, 2010: $275.00 per week
$50.00 Non-Refundable Application Fee to be included with the registration form
Payment by check or credit card (MC, Visa, Amex, Discover) Located in Upper NW DC