2019 Summer Camp Registration

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Please complete the form below, when finished, make a payment through the provided button on the Camps page of the website. If you are paying for multiple weeks you will need to edit the amount field to reflect the total payment needed. You will receive a receipt from PayPal with record of your transaction and we will reach out to you about next steps. You can also sign up and make a payment at a later date as long as it is before 4/1/2019. Payment per camp is $380 before 3/1/2019 and $430 after 3/1/2019. A fee will be held of $150 if a cancellation is made after 4/1/2019. There is no refund after 5/1/2019.

Film & Story Summer Camp at St Alban's

Camper Info

Camper's Name *

Have you read the payment and refund policy above? *

Yes I have read and understand the refund policy

Required

Gender *

Male

Female

Other:

Age *

Birthdate *

YYYY

Physician Name *

Physician telephone *

Medical plan and policy # *

Allergies, physical or medical limitations or anything else you would like me to know. *

Your child's interest and experience

wish they had more experience

wish they had more interest

Family's interest

One of Child's favorites

making projects by hand

film making

Attending Art Museums

Fine Art

critical thinking skills

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Camp Sessions

Camps are $380 per week until 3/1/19. After 3/1/19 all camps cost $430. The last day to cancel is 5/1/19. If you cancel after 4/1/19 $150 will be held from your payment. No refund will be issued if you cancel after 5/1/19. Please select the camp your child wishes to attend. If you wish to attend more than one you will need to adjust your payment accordingly.

Please select a desired date and camp. *

Session 2: June 24 -28 "Film & Story Summer Camp" ; ages 10-16

Required

Parent / Guardian #1 *

Parent / Guardian relationship Info

Email Address *

Home Address *

Primary Phone *

Is it okay to Text Primary phone *

yes

Parent / Guardian #2

Email Address

Home Address

Primary Phone

Is it okay to Text Primary phone

yes

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Persons authorized to pick up child from camp, please provide their name telephone *

INDEMNIFICATION, WAIVER AND RELEASE:

By entering your name on the line below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

In consideration of my, or my child’s participation in MPHallDesign Camp, taught by Mason Hall, I agree to: *

1.Assume all risk of injury to my child and all risk of damage to or loss of property arising out of my own or my child’s participation in this program.

2. Release, discharge and waive any and all responsibility of Mason Hall, Piper Lemons and MPHallDesign, 973 Curtis Str, Albany Ca, from and against liability for any injury and for damage to or loss of property which may arise out of participation in this program.

3. Indemnify and hold harmless Mason Hall and Piper lemons from and against all liability, claims and demands, loss and damage arising out of camp participation.

4. by checking this box I agree and declare that the above statements are true to the best of my knowledge and by signing below through an electronic signature I agree to all statements provided in this document as such.

Required

Signature *

Date *

YYYY

CONSENT FOR EMERGENCY MEDICAL TREATMENT:

By entering your name on the line below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

As parent or authorized representative of the child / student listed above, I hereby give consent to Mason Hall and or Piper Lemons to obtain all emergency medical care prescribed by a duly licensed physician for said child. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above. The undersigned further agrees that Mason Hall or Piper Lemons is not legally or financially liable for any claim rising from any consent given in good faith in connection with such advised treatment. This authorization and consent to treatment of said minor is given to Mason Hall and Piper Lemons and shall remain effective until December 31, 2019. *

YYYY

Name: *

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