Summer Camp Registration
Fill this out as Step 1 of 2 to register for summer camps at Schools of Rock Evanston & Highwood
Email address *
Parent Name *
Your answer
School Location: *
Camp Selection: *
Required
Student Information: Name *
Your answer
Student's Birthdate: *
MM
/
DD
/
YYYY
Student's Age: *
Your answer
Instrument(s) *
Your answer
Parent Email *
Your answer
Address, City, State, Zip *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Did someone refer you to this camp? If so, who? *
Your answer
Address, City, State, Zip *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Additional Guardian Information (Designated for anyone who will be picking up / dropping off child)
Your answer
Release Information: I, as the parent / guardian of the student listed on this form, certify that I have read, understand and agree to comply with the School of Rock's policies for Summer Camp. Please initial below. *
Your answer
As the camper listed on this form, I certify that I have read, understand and agree to comply with the School of Rock's policies for Summer Camp. Please initial below. *
Your answer
It is okay for School of Rock to use my child's image or recording for promotional materials. Your child's name will not be disclosed. *
I allow the staff of School of Rock to treat my child in the event that it becomes necessary, according to the information provided on the medical form attached. Please initial below. *
Your answer
Medical Information and Emergency Contact NAME: *
Required of all students: To be completed by parent/guardian.
Your answer
Emergency Contact Email: *
Your answer
Emergency Contact Home Phone: *
Your answer
Emergency Contact Cell Phone: *
Your answer
Physician Information: Name & Practice Group *
Your answer
Physician Information: Address *
Your answer
Physician Information: Phone *
Your answer
Medical History and Insurance: Please list any of this student's medical history or health conditions (e.g. hospitalizations, asthma, diabetes, epilepsy, heart conditions, unusual childhood diseases, or any health conditions for which your child has been diagnosed or treated): *
Your answer
Does the student have any drug medication, food or contact allergies? *
If so, please specify:
Your answer
Is this student taking any medications? *
If so, please specify:
(Include drug name, dosage, condition and frequency for each)
Your answer
Does this student self-medicate? *
Provide Medical Insurance information below: *
Include: Name of insurer.carrier, address, group and policy number, employer/plan sponsor.
Your answer
I understand that to complete my registration I need to: (Choose 1) *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of School of Rock. Report Abuse - Terms of Service