Drop & Shop Kids Camp

Parent/Guardian First name*

Parent/Guardian Last name*

List Names/Ages of Children*

Email*

Phone*

Address*

Please list any allergies, medications or conditions that may affect participation. *

Emergency Contact - Name, Phone Number & Relation*

Multi choice*

Mon, Dec 22nd

Tue. Dec 23rd.

Wed. Dec 24th

All 3 Days

Days Attending*

Dec. 22nd 10-3$65

Dec 23rd 10-3$65

Dec 24th 10-2$55

All 3 Days$150

I willingly give permission for my child to participate in all activities. I give permission to the designated staff member to secure medical treatment for my child in the case of an emergency. *

Yes

I understand behavior issues will not be tolerated and will result in immediate removal of the student without refund. Students are expected to conduct themselves in a respectful manner.*

Yes

I agree to hold Seismique, and/or their assignees, employees, and staff harmless, nor responsible in the event of injury, accident, or death.*

Yes

I hereby authorize and consent that Seismique and/or their assignees, employees, and staff have absolute right to copyright, publish, sell, or assign any and photographs, pictures, video recordings, or sound for marketing purposes.*

Yes

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