GSU Center for Performing Arts Summer Theatre Camp for June 2022
REGISTRATION FORMS and PARTICIPATION AGREEMENT/RELEASE FORM
Both the camp participant minor and the participant’s Parent or Guardian must sign and execute below.

Camp Registration

This camp registration will ask for general camper and parent/guardian information, emergency contact information, and camper pick-up designations.

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* 1. Camp Participant Information

Full Name

Date of Birth

Grade

Personal Pronoun

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* 2. How old will the registered camper be at the time of this program?

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* 3. Parent/ Guardian Contact Information

Parent/Guardian Full Name *

Relationship *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number 1 (With Area Code) *

Phone Number 2 (With Area Code)

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* 4. Parent/Guardian Information

Parent/Guardian Full Name

Relationship

Email Address

Phone Number 1 (With Area Code)

Phone Number 2 (With Area Code)

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* 5. Emergency Contact
(Please include another person other than the parent or guardian.)

Full Name *

Relationship *

Email Address *

Phone Number 1 (With Area Code) *

Phone Number 2 (With Area Code)

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* 6. Medical/Allergy Information
Medical conditions and special needs:
Campers may be exposed to potential allergens including, but not limited to chocolate, cocoa, coconuts, eggs, fish, milk, peanuts, shellfish, soy, tree nuts, gluten and wheat. Parents and campers should exercise appropriate caution particularly when making cafeteria selections and dining .

Does the camper have any allergies or dietary restrictions?
If Yes, please answer the following:

Allergies and dietary restrictions:

Self-administered medication:

Self-administer medication description:

Doctor name:

Doctor phone with area code:

Doctor location:

Additional Information:

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* 7. Designated Adult Pick-up:
Besides the parent/ guardian(s) listed previously, the following adults are authorized to pick-up my child at the conclusion of registered Summer Theater Camp activities.

*Please Note: Designated pick-up adults MUST have a valid state-issued photo ID.

Authorized adult #1 name/ phone number

Authorized adult #2 name/ phone number:

Authorized adult #3 name/ phone number:

Authorized adult #4 name/ phone number:

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* 8. Consent for Camper Self-Sign-Out:
Generally, campers are to be picked-up by a parent, guardian or other designated adult with a valid state-issued photo ID. We recognize that due to the age and maturity of some campers that some parent(s)/ guardian(s) are comfortable with their child(ren) signing themselves out at the end of camp. Parents/ guardians with campers aged 15 or above at the beginning of camp may
request that their child be permitted to sign themselves out at the end of registered camp activities each day.

Important: Governors State University does not allow unaccompanied non-GSU student minor children on campus. Unaccompanied campers MUST leave campus after sign-out. As the responsible parent/ guardian, I consent to allow my child, aged 15 or older at the time of camp attendance to self-sign-out, and accept full and complete responsibility, holding Governors State University, its agents and affiliates harmless in all cases.

Responsible parent/guardian name (serves as signature):

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* 9. OVERVIEW

Governors State University Center for Performing Arts (GSU CPA) is committed to presenting a safe learning environment for all camp participants. Camp will be held entirely in person. Camp will meet in person daily. All experience levels welcome. Camp is for Ages 8 - 15 and will be from 9a-3p Monday - Friday (five weekday sessions.) The final performance will start Friday at 7p. Cost is $250 per week for each camper. The camp registration includes a box lunch on Friday and admission for two people to the final performance. Additional purchases are available, $10 per person, $5 for 14 or younger.
ALL SALES ARE FINAL. There are NO REFUNDS OR CANCELLATIONS after registration is complete.

I have read, understood, and agree to the above terms

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* 10. Please choose a camper Box Lunch option for Friday, June 24 end of camp celebration.

Turkey sandwich meal

Roast Beef sandwich meal

Vege sandwich meal

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* 11. PARTICIPANT PHOTO / VIDEO / STREAMING RELEASE

I hereby authorize GOVERNORS STATE UNIVERSITY to film, tape, or otherwise record my or my minor child camp participant's likeness, image, voice, interview and/or performance for the CPA produced and presented “children’s theatre summer camp program” to be held in our theatre and/or other social media platforms. I also authorize GOVERNORS STATE UNIVERSITY to use and authorize others to use all recordings, videotape or film, or any part thereof, on an irrevocable and unlimited basis in all markets and media now known or hereafter devised, including online streaming. I additionally authorize GOVERNORS STATE UNIVERSITY to use my or my minor child camp participant's likeness, voice, performance, and biography for both archival purposes and to publicize or promote future programs.

I agree to the above terms

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* 12. PARENT/GUARDIAN AUTHORIZATION & WAIVER OF LIABILITY

Please be aware that in registering yourself and your minor child/ward for participation in this Summer Theatre Camp program presented by GSU CPA and its contracted camp counselors, you, for yourself and as the parent or legal guardian of the child named above, will be waiving and releasing all claims for injuries that you and your child might sustain arising out of or in connection with this program or its affiliates.

I agree to the above terms

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* 13. PERMISSIONS ACKNOWLEDGEMENT

I hereby give permission for my child to participate in all summer theatre camp programming and activities. I agree to assume the full risk of all injuries, damages, or losses regardless of severity which I or my child or ward may sustain as result of participating in any activities connected or associated with any such programs and I waive and relinquish all claims I or my child or ward may have against Governors State University, the Center for Performing Arts, and its officers, directors, employees, agents, contractors, and volunteers as a result of participating in the activities and programs in connection with summer theatre camp.

I, on behalf of my child, release, indemnify and hold harmless Governors State University, the Center for Performing Arts, and its officers, directors, employees, agents, contractors, and volunteers from and against any and all liability, actions, debts, claims and demands of every kind whatsoever, specifically including, but not limited to, any claim for negligence or negligent acts or omissions and any present or future claim, loss or liability for any type of injury to person or property that my child may suffer, for which my child may be liable to any other person, or that may or does arise out of my child’s participation in the Event. Furthermore, I acknowledge that I have received, read, and understand camp policies, procedures, code of conduct, and video/photo/media release forms, and agree to abide by them. I hereby grant the permissions stated therein.

This RELEASE contains the entire agreement between the parties and the terms of this RELEASE are contractual and not a mere recital. I have been given ample opportunity to read this document and I understand and agree to all of its terms and conditions. I understand that I am giving up substantial rights (including my right to sue), and acknowledge that I am signing this document freely and voluntarily, and intend by my signature to provide a complete and unconditional release of all liability to the greatest extent allowed by law.

My electronic signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns.

I agree to the above terms

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* 14. I HAVE READ AND FULLY UNDERSTAND THE ABOVE PROGRAM DETAILS, MEDIA WAIVER, AND WAIVER OF LIABILITY, AND HEREBY RELEASE ALL CLAIMS.

Yes

GSU Center for Performing Arts Summer Theatre Camp for June 2022REGISTRATION FORMS and PARTICIPATION AGREEMENT/RELEASE FORMBoth the camp participant minor and the participant’s Parent or Guardian must sign and execute below.

Camp Registration

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* 1. Camp Participant Information

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* 2. How old will the registered camper be at the time of this program?

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* 3. Parent/ Guardian Contact Information

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* 4. Parent/Guardian Information

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* 5. Emergency Contact(Please include another person other than the parent or guardian.)

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* 7. Designated Adult Pick-up:Besides the parent/ guardian(s) listed previously, the following adults are authorized to pick-up my child at the conclusion of registered Summer Theater Camp activities.*Please Note: Designated pick-up adults MUST have a valid state-issued photo ID.

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* 10. Please choose a camper Box Lunch option for Friday, June 24 end of camp celebration.

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* 14. I HAVE READ AND FULLY UNDERSTAND THE ABOVE PROGRAM DETAILS, MEDIA WAIVER, AND WAIVER OF LIABILITY, AND HEREBY RELEASE ALL CLAIMS.

GSU Center for Performing Arts Summer Theatre Camp for June 2022
REGISTRATION FORMS and PARTICIPATION AGREEMENT/RELEASE FORM
Both the camp participant minor and the participant’s Parent or Guardian must sign and execute below.

* 5. Emergency Contact
(Please include another person other than the parent or guardian.)

* 7. Designated Adult Pick-up:
Besides the parent/ guardian(s) listed previously, the following adults are authorized to pick-up my child at the conclusion of registered Summer Theater Camp activities.

*Please Note: Designated pick-up adults MUST have a valid state-issued photo ID.