Name of camper ______________________________________________ Circle:    Male    or    Female

Street Address ___________________________________________________________________________________

City/State/Zip ____________________________________________________________________________________

Home Phone (       )__________________Parent(s) Email __________________________________________________

Age _________   Birth date   _____/____/____   Grade level(Fall 2009) ______School ___________________________

Parent name (s) __________________________________________________________________________________

Mother contact phone (Day) _________________________ (Cell) ________________________

Father contact phone (Day) _________________________   (Cell) ________________________

EMERGENY RELEASE INFORMATION

Emergency Contact (other than parent) Name _______________________________Phone (_____)________________

Health Insurance Carrier and Number __________________________________________________________________

Doctor’s name ___________________________________________Phone (_______)____________________________

Please note all physical/medical conditions/restrictions of which our staff or medical personnel should be aware:

Please note any medications camper takes on a regular basis:

Please note allergies:

I give representatives of LITTLE LAKE THEATRE COMPANY permission to seek emergency medical attention for

______________________________ in the event that I cannot be reached or until I am able to be present. 

_______________________________________________________________     _____________________________

Signature of parent/guardian                                                                                          Date

For the camper to complete: I am interested in attending Theatre Arts Summer Camp because ___________________

________________________________________________________________________________________________

One TASC t-shirt is included in every enrollment payment. 

Circle ADULT tee size request:    Small        Medium     Large       XLarge

  PAYMENT INFORMATION   Camper’s name __________________________________________

             ____ I have enclosed a check for full payment of early enrollment fee of $195.00.  This payment must be                                     postmarked no later than May 31, 2009.  This represents payment in full for Session:  One   /  Two.

            ____ I have enclosed a check for $215.00. This represents payment in full for Session:  One     /     Two.

            ____ I have enclosed a deposit of $25.00 to reserve space in Session One / Two.  This deposit will be credited to my enrollment fee. I understand my deposit is non-refundable. If camp is filled when Little Lake receives this application the deposit will be returned.  I also understand that the full fee for camp is $215.00 and that Little Lake must receive the remaining payment in full by the completion of the orientation meeting.

            ____ I have enclosed other payment of ____________________________________________

Camp fees are not refundable once the camp session has started.   

Parent signature  ______________________________________________________________________________

Parent name (Please print)   _____________________________________________________________________

CAMPERS and PARENTS:  Please read and sign Camp Safety Sheet and submit it with your application or bring it with you to orientation. If you are a returning camper who will not be attending the orientation, please return the Safety Sheet no later than the first day of camp.  Campers WILL NOT be allowed to participate in any camp activities until Little Lake has received the completed the Safety Sheet.

 Safety Sheet

Mail to: TASC   Little Lake Theatre    500 Lakeside Dr. South    Canonsburg, Pa. 15317  

For office use only:  

PIF     $195.00   /    $215.00        Date _______________    Check # _________________

Amount received ___________   Date ______________      Check # _________________ Amount due ______________