PARENT INFORMATION :
Primary Email: Secondary Email: Mother's First Name: Last Name:
Father's First Name: Last Name: Primary Contact Name: Phone #:
Alternate Contact Name: Phone #: Emergeny Contact #: Phone #
Street Address: APT# City: Zip: STUDENT INFORMAION:
Number of Children: 1 Child 2 Children 3 Children 4 Children
STUDENT 1:
Student First Name: Last: Student Age: Student Birthday: Years of Gymnastic or Performing Experience:
STUDENT 2:
STUDENT 3:
STUDENT 4:
Our child/children will be registering for the following weeks:
Method of Payment: PayPal By Mail - Check
WEEK 1 (June 6-10)
WEEK 2 (June 13-17)
WEEK 3 (June 20-24)
WEEK4 (June 27-July 1)
WEEK 5 (July 4 -8)
WEEK 6 (July 11- 15)
WEEK 7 (July 18-22)
WEEK 8 (July 25-29)
WEEK 9 (Aug 1-Aug 5)
EXTRA WEEK (Aug 8-12)
SPECIAL EVENTS
Winter Camp (Dec 27-30)
Spring Camp (Mar 14-18)
STUDENT HEALTH Please specify any health problems you are aware of as your child's safety is important to us. Check "NO" where there are not problems. "NO" Health related problems
Chronic Ailment Bones or Joints Allergies to food Heart
Allergy to insect sting Respiratory Muscles If "Other" please explain
Behavior health problem
Does your child currently take any medication? If so, please list all medications and a brief explanation why this medication is being taken . Is your child current on all required immunizations? Has your child had Chicken Pox? Has your child had Measles?
I acknowledge that I have read the above mentioned facts. I certify that all answers are, to the best of my knowledge correct and true. I grant permission for photographs and or videos to be taken of my child and Chimal Circus Arts can utilize these images in brochures, websites, and other camp materials. Chimal Circus Arts reserves the right to cancel the camp due to insufficient registration Parent/Guardian Electronic Signature
