Parent/ Caregiver Information

Parent/ Caregiver First and Last Name *

Email Address *

Phone Number *

Alternate Phone Number

Emergency Information

Emergency Contact Name *

Relationship *

Phone Number *

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Secondary Contact Name

Relationship

Phone Number

Medical Information

Physician Name *

Physician Phone Number *

Medical Insurance Company *

Insurance Policy Number *

List all known medical conditions, including allergies to food or medications. *

List any and all over-the-counter and/or prescription drugs taken regularly. *

Authorization for Emergency Care to a Minor

As the Parent/Guardian of the aforementioned child, I authorize such diagnostic, medical, and/or surgical treatment of my child as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury, by licensed emergency medical professionals. *

Yes

Photo Release Statement

I give permission and consent for photographs to be taken of my child during camp session activities. I further give permission and consent that any such photographs may be published and used by Yellow Brick Theater to illustrate and promote the camp experience and its programs. I release Yellow Brick Theater from all claims, demands, and liabilities whatsoever in connection with the above. *

Yes

No

Camp T-Shirt Order

*

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. *

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High School Summer Camp tuition is $235. Payment plans are available.

A DISCOUNT is available for siblings. Deduct $25 off the price of tuition for the second child enrolled. For a third and/or fourth child, deduct $50 off of each child's tuition.

REFUND POLICY: A full refund for High School Camp tuition is available if YBT is notified before June 10th. After June 10th, a 50% refund will be given. All refunds will include a 3.5% deduction to cover PayPal fees.

Check/cash payments may be sent to: Yellow Brick Theater c/o Dionne Meyer 3746 Mesquite Dr. Beavercreek, OH 45440. Checks may be made payable to Yellow Brick Theater. A $25 fee will be charged for returned checks.

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YBT HS Summer Camp (Full Tuition)

YBT HS Summer Camp (2nd Child Enrollment)

YBT HS Summer Camp (3rd Child Enrollment)