The Show Must Go On2019 Winter Vacation Theatre Camp Registration Form

Maine Week: Feb 18-22NH Week: Feb 25-Mar 1

Mon-Fri 9am-3pm (extended hours available)

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How did you hear about us?

A re d e i i dep sit is d e it t is re istr ti p e t st e re ei ed t e st d s e re t e irst d p e ti i p t ee s e re p e p id e t e dep sit i e re ded t e ee s e re p e p id e t e dep sit i e re ded A ter p s e t ere i e re ds

Camp will be held at 73 Court Street (The South Church Offices), Portsmouth, NH 03801With a performance on Friday at the South Church Parish Hall (292 State Street)

Upside Arts d es t pr ide edi i s r e r p rti ip t i pr r ered t e dersi ed re t r rdi t is st de t i r d ere t ri e t e dire t rs d te ers Upside Arts s e ts r t e

dersi ed t se t t edi e er e tre t e t ere re e se Upside Arts r d i s r pers i ries s se t t t st de t s p t r ide e t e d sed r p rp se dee ed

e ess r t pr te Upside Arts ed ti pr r it t pe s ti Upside Arts is t resp si e r tr sp rt ti st de ts t r r sses re e rs s r per r es.

Additi ti t e t d

Tuition ncludes an pside rts T shirt

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⇒ Tuition balance is due 1 days prior to camp start date ⇐Questions? Contact Seraphina Caligiure at

seraphina@theupsideartscompany.org or 603-978-8171

Mail completed form and payment to: Upside Arts, Attn: Vacation Camp, 216 Bartlett St, Portsmouth, NH 03801

Or send a digital copy to seraphina@theupsideartscompany.org

For Office Use Only: Date Paid: ______________ cc auth/Check # ________ confirmationsent_________

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Cost of Camp: $325.00 ($75.00 Deposit)essi

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Medical Release & Information Form

Student Name __________________________Date of Birth _________

As the undersigned parent and/or legal guardian of the student listed above, I hereby give permission for my student to be given emergency treatment as needed by members of Upside Arts (UA). I give permission for the student to be transported by ambulance to an emergency center for treatment. In the event that I, my student’s listed emergency contact, or my preferred physician cannot be contacted, I consent to medical, surgical and hospital care treatment and procedures to be performed for my child by a licensed physician or hospital when deemed immediately necessary or advisable by a physician to safeguard my child’s health. I agree that I will not hold UA or any member of its staff liable for damages, injuries or losses during the student’s participation with the UA education programs.

Signature _______________________________Date ______________

Parent/Guardian Name(s) _____________________________________

Phone __________________Alternate Phone______________________

Non-Parent Emergency Contact________________________________

Phone ___________________Alternate Phone ____________________

Physician Name_____________________________________________

Physician’s Place of Practice __________________Phone ___________

Medical Insurer/Health Plan: ________________Policy #: ___________

Please list any important health related information about your child (allergies, medications, special learning needs)

__________________________________________________________ __________________________________________________________ __________________________________________________________