Art & Dance Day Camp Registration Form


Child’s Information
MM slash DD slash YYYY
Parent/Guardian Information
Additional Emergency Contact Information
Agreements I agree to the following:
  • The child will follow directions of camp instructions and assistants;
  • The child will not bring any over-the-counter medications to camp;
  • The child will wear closed-toed shoes to camp each day.
  • The camp instructors and assistants are not permitted to give the child any medication;
  • Complete an evaluation form at the end of camp.
Photo Release

I hereby grant permission to The Filling Station and the Atlantic Dance Theatre, their legal representatives and assigns, and those acting with their authority to copyright and use, re-use, and publish, and re-publish photographic portraits or pictures, television/video, web and radio/audio recordings of the above-named participant without further consideration, and I acknowledge that the Filling Station may crop or treat the photographs at its discretion. I hereby waive any right that I may have to inspect or approve the finished product or products or the advertising copy, printed or recorded.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by The Filling Station and the Atlantic Dance Theatre during the camp. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless The Filling Station and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of participating in camp sessions.

In case of injury to said child, I hereby waive all claims against The Filling Station and the Atlantic Dance Theatre including all instructors, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. I hereby warrant that I am the parent or guardian of the above-named applicant and have every right to sign on his/her behalf in the above regard. I state further that I have read the above authorization, release and agreement, prior to its execution, and that I am fully familiar with the contents thereof.

Signing on behalf of applicant:
MM slash DD slash YYYY