Student’s Name: __________________________________________________
Address: ________________________________________________________
E-mail: __________________________________________________________
Phone: ( )___________ School: ____________________________________
Birth Date: ___/___/_____ Grade: _________ Sex: _________
Mother’s Name: __________________________________________________
Work Phone:( )___________ Pager: _________ E-mail: ________________
Father’s Name: ___________________________________________________
Work Phone:( )___________ Pager: _________ E-mail: ________________
Emergency Contact: _________________________ Phone:( )____________
I authorize my child to participate in all camp activities, including leaving EBMC facilities while under adult supervision. I agree that all media produced is exclusive property of EBMC, all rights reserved.
Signature of Parent/Guardian: _________________________ Date: __________
ILLNESS, ACCIDENT, OR INJURY: In the event of a serious illness or injury, I authorize emergency medical care for my child. I wish my child to be taken to the nearest Emergency Medical Facility, and the following doctor notified:
Doctor’s Name: ____________________________ Phone:( )______________
Insurance Company and Policy Number: ________________________________
Parent(s) Signature: _____________________________ Date: ______________
Summer Media Camp
2010 – July 12-30, 2010
Time: Monday through Friday, 10:15 AM to 2:30 PM
Cost: $750.00 per session Ages: 13-17
Cancellation/Refund Policy:
A Matriculation / Administrative Fee of $100. will be deducted from the paid fee if Teen / Parent cancels Summer Teen Media Camp 2010 before Commencement of STMC. No Refunds after STMC 2010 Commencement.