<p> Ross Ragland’s Summer Youth Theater Camp A three week long performing arts camp for 10-18 year olds</p><p>June 20 2016 –July 8 2016 Camp hours, Monday-Friday, 8:30am-3:30pm Performances: Saturday, July 9, 2016 @ 2 p.m. & 5:30 p.m. The Summer Youth Theater Day Camp offers an intensive three week session providing a complete immersion into the world of theater and the arts. Classes include acting, dance/movement, voice and art projects. Camp culminates with two performances of Disney’s Willy Wonka Junior. </p><p>REGISTRATION FORM Complete and mail to: The Ross Ragland Theater 218 North 7th Street, Klamath Falls, OR 97601 Or FAX: 541-884-8574</p><p>Student’s Name: Age: DOB: School: Grade: Gender: M F Parent(s)/Guardian(s): Address: City: Zip: </p><p>Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Email Address: Tuition & Payment Information: Regular Registration Tuition: $ 399.00 due by 6/20/2016 (Additional siblings $300)  Balance due by Monday, June 20, 2016 to ensure participation.  Balance is non-refundable after 4 p.m. on Monday, June 20, 2016.</p><p>___ Check enclosed. (Make checks payable to The Ross Ragland Theater) ___ Charge my Card: Name on Card Number on Card Amount: $ Exp. Date: CVC # (On Back): Signature______Photo Consent</p><p>□ I agree that photographs of my child/children taken by RRT may be used for promotional purposes including brochures, advertising, and the RRT website by RRT, but will not be used by other organizations without additional written consent.</p><p>Signature Date </p><p>EMERGENCY CONTACT & MEDICAL INFORMATION</p><p>Child’s Name: DOB: Gender: M F Parent’s/Guardian’s Name (print) Home Phone: ( ) Cell Phone: ( ) Address: City: Zip: </p><p>ALTERNATIVE EMERGENCY CONTACTS</p><p>Primary Emergency Contact: (print) Phone ( ) Cell: ( ) Address: City: Zip: Secondary Emergency Contact (print) Phone ( ) Cell: Address: City: Zip: </p><p>MEDICAL INFORMATION</p><p>Hospital/Clinic Preference: Physician’s Name: Phone: ( ) Insurance Company: Policy Number: Allergies/Special Health Considerations: </p><p>I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.</p><p>Parent’s/Guardian’s Signature Date</p>