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SHINE! Theatre Camp Registration 2019
Use this form to enroll in the 2019 Shine! Theatre Camp. Camp is open to students with special needs ages 8-18.

Campers MUST be able to attend both full weeks of camp, July 22-26 and July 29-August 2 AND be available for performances in the afternoon and evening of August 2.

$50 participation fee per student, refundable until July 8, 2019. Withdrawing from camp after July 8 will forfeit any refund of the participation fee.

All camp activities will take place at Winston-Salem Theatre Alliance, located at 1047 W. Northwest Blvd, Winston-Salem.

**NOTE: This form MUST be completed by a parent or legal guardian.**

Email address *
Student First Name *
Your answer
Student Last Name *
Your answer
Preferred Name
Your answer
Ethnicity
Your answer
Gender
Your answer
Preferred pronouns
Date of Birth *
Your answer
CONTACT INFORMATION
Parent/Guardian Name *
Your answer
Address *
Your answer
Address
Address line 2
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent/Guardian Primary Phone Number *
Your answer
Receive text messages?
Type "yes" if you approve Shine! staff communicating via text.
If "yes" for previous question, enter mobile number:
Your answer
EMERGENCY CONTACTS
Please list names and contact information for two emergency contacts (besides parent information above). In case of emergency, we will contact these people if parent or guardian cannot be reached.
1 Emergency Contact *
Your answer
1 Emergency Contact Relationship *
Your answer
1 Emergency Contact Number (Home) *
Your answer
1 Emergency Contact Number (Work)
Your answer
1 Emergency Contact Number (Mobile)
Your answer
2 Emergency Contact Name *
Your answer
2 Emergency Contact Relationship *
Your answer
2 Emergency Contact Number (Home) *
Your answer
2 Emergency Contact Number (Work)
Your answer
2 Emergency Contact Number (Mobile)
Your answer
MEDICAL INFORMATION
Primary Care Physician *
List name and contact information of student's primary care physician. List date last seen.
Your answer
Medical History *
List/explain student's medical history.
Your answer
Medications *
List all medications currently taking, along with dosage and the name of the prescribing doctor. If none, type "None."
Your answer
Allergies *
List any allergies. If none, type "None."
Your answer
Other
Indicate any other relevant medical information.
Your answer
Assistive Devices *
List any adaptive aids or technology the student uses. E.g. low vision aids, mobility devices, communication devices, etc. If none, type "None."
Your answer
VISION
Is the student visually impaired?
HEARING
Is the student hearing impaired?
Mobility
Details about student's mobility, including level of assistance required
Your answer
Behavior *
Describe any special behavioral or emotional needs for your child (e.g. response to adult direction, expression of anger, response to changes in routine). Include any keywords or familiar phrasing our staff and volunteers may need. If none, type "none."
Your answer
INDIVIDUAL STUDENT NEEDS
Physical Activity *
Does your child have any restrictions for participating in physical activity? If yes, describe
Your answer
Diet *
Does your child have any special dietary needs? If yes, describe. (Please note: Shine! camp will not provide any food items; all students must bring their own snacks and lunch, and sharing will not be permitted, in order to minimize any chance of food allergy contaminants.)
Your answer
Other
List any other individual needs for your child
Your answer
Students with significant medical needs (i.e. needs care in the course of the day that requires special training), who require assistance with toileting needs (i.e. wears diapers or cannot use the toilet without assistance), or who have significant dietary and food allergy concerns must attend with a parent, guardian, or other adult caregiver. Will the student attend with a caregiver?
WAIVERS AND AGREEMENTS
Type your full name in the text line below each paragraph to indicate your agreement. Your typed name is considered a legal signature.
Camp Agreement *
I have completed this registration form completely and honestly, and I have provided detailed information about my child's medical history and needs. I agree to contact Shine! staff with any changes in my child's medical history, allergies, medications, or care. I understand that Shine! staff are not medical professionals and that Shine! staff and volunteers will work diligently to ensure the needs of my child are met. However, I understand that Shine! staff reserve the right to determine that my child's medical needs and/or behavior necessitate that he/she/they are not able to attend camp without a caregiver. If I am unable to attend with my child or provide an adult caregiver, my child may be asked to leave camp, forfeiting the $50 fee.
Your answer
Medical Authorization *
I give my consent for the above named student to receive routine care for minor injuries and illnesses. This treatment could include physician-prescribed medication and non-prescription medication as deemed appropriate by health services personnel, should staff deem it necessary to call emergency services or medical professionals are in attendance at camp. I also give my consent for my child to receive emergency medical and surgical treatment determined necessary by an attending physician. I understand that Winston-Salem Theatre Alliance (WSTA) staff will make every reasonable effort to contact me before any prescriptions, doctor appointments, or emergency treatment is administered. I request that WSTA personnel administer my child's medications during the camp day, if applicable, as directed in an attached note, and I will provide said medications in a clearly labeled container each day. I understand that any such medication will be given by a staff person who is not a licensed nurse or doctor, but medications will be given according to medical instructions provided by me. I also agree to notify WSTA staff of any change in medical condition or medications. (Please type your full name)
Your answer
Waiver of Responsibilities *
When I submit this application/registration form for Shine!, I, the undersigned, do hereby release and discharge Winston-Salem Theatre Alliance (WSTA) and all Shine! staff and volunteers and any of its agents, affiliates, employees, and servants from any and all claims, liabilities, demands, or rights which I, or any of my friends or relatives, may have against said Program or its agents, affiliates, employees, or servants on account of connecting with or growing out of any injury, accident, loss, or damage or suffering that I or my immediate family may hereafter sustain while on the premises or property owned, leased, or used by WStA arising out of acceptance of this application for the Shine! camp, whether said property be known as WSTA or any other named designation or location. I have read, or caused to be read to me, the foregoing and do hereby acknowledge that I fully understand each and every part thereof. I acknowledge receipt of the Shine! regulations outlined in this registration form and agree to abide by them. The signature of the parent/legal guardian below certifies that he/she has read and completed the foregoing application accurately. (Please type your full name)
Your answer
Media Agreement *
In order to capture documentation during activities associated with Shine! Theatre Camp, photos, video, or other forms of electronic media will be collected by students, volunteers, and camp staff. This media may be used for promotion of Shine! Camp and Winston-Salem Theatre Alliance, including but not limited to posts on our social media accounts, website, e-newsletter, and in association with grant applications. Campers will be identified by first name only.
Other Documents
You will also need to submit:

- 1 copy of student's IEP or (if home schooled or attends private school) letter of eligibility from student's doctor
- Instructions for any medications that Shine! staff may need to administer

Contact jlawrence1@gmail.com with any questions.

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