One Eleven's 2021 Summer Theatre Camp Registration Form

Child's First Name *
Child's Last Name *
Child's Gender *
Grade (Fall 2021) *
T Shirt Type *
T Shirt Size *
Allergies/Dietary Restrictions/Medical Needs (if none, please type: N/A) *
Parents' Names *
Primary Contact Phone Number *
Secondary Contact Phone Number *
Family Mailing Address *
Family Email Address (This is where most communication will take place, so make sure it is one you check often!) *
Secondary Email Address (optional)
Emergency Phone Number (besides those listed above) *
Payment Amount *
Payment Type *
PayPal Email - If paying online, please specify the email used to make the payment so we can match it up in our records.
We are in need of some adults to help with check-in, check-out, watching kids during the lunch hour, and also a full-time camp nurse or "camp mom." If you are able or interested in helping in any of these areas, please check the boxes below, and we will contact you!
Any other notes or questions? Please let us know below! We are excited to have your child join us at camp this year!
LIABILITY WAIVER: (PLEASE SIGN WITH SIGNATURE OF PARENT OR LEGAL GUARDIAN AND TODAY'S DATE.) I hereby enroll my child in One Eleven Theatre’s Day Camp. In signing this application, I certify that he/she is healthy and free of problems that could adversely affect his/her stay or that of other campers at the Camp. I grant permission for the applicant to participate in all planned camp activities. I hereby grant One Eleven Theatre Co. and its agents full authority to take whatever actions they deem necessary regarding my child’s health and safety, and I fully release One Eleven Theatre Co. from any liability in connection there within. In the event of an emergency, I understand that prudent attempts will be made to contact the undersigned immediately. I understand that I will be responsible for payment of all medical and medication bills. I understand that my child must comply with the camp’s rules and standards of conduct and that the organization may terminate my child’s participation in the camp program if he/she does not maintain these standards. One Eleven Theatre Co. is not responsible for lost, stolen, or damaged personal articles. I authorize One Eleven Theatre Co. to have and use photographs, audio and video recordings, and comments of the person named on this application as needed in promotional materials and public relations programming. I individually and corporately agree to hold harmless One Eleven Theatre Co., its volunteers, agents, employees and officers irrespective of any negligent act or omission by One Eleven Theatre Co. and/or those individuals arising from or related in any way to Disney’s Moana Jr. Summer Camp Program. Signature of Parent or Legal Guardian and Today's Date: *
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