Student Name

           Phone #s:

Parent(s) Name

     Cell      

Address

  Home     

City/St/Zip

   Work  

E-Mail(s)

Grade in school      

Emergency Contact

          Phone # Phone#

Medical Information

 Medical Consent and Release of Liability  

I, the undersigned parent or guardian of __________________, a minor, do hereby authorize the directors and teachers of HCCMS Drama Camp as agents for the undersigned to consent to medical treatment in an emergency. I hereby release and discharge HCCMS. from any and all claims for personal injuries. I agree that photographs of this student taken during workshop hours may be used for promotional purposes by HCCMS Drama, but will not be used by other organizations without additional written consent.  

Signature _________________________________________________  Date______________________                                                                      

Payment Information

To secure enrollment, please send $100 payable to HCCCMS Drama Booster Club, to the address below or pay online by credit card following the link on hccmsonline.org.  Full payment is due before the first day of class.  REFUND POLICY: Full refund only if class is cancelled by HCCMS. I understand the cost and refund policy for HCCMS Drama Kids Camp.

Signature__________________________________________________ Date___________________

E-mail the completed form and pay via paypal, or  Mail completed form and a check to secure your child’s spot to:  

Harris County Carver Middle School

Attn.: Merrill Cheyne

11969 US Hwy 27

Hamilton, Georgia 31811

Checks made out to HCCMS Drama Booster Club

In the check memo blank put: your child’s name