Student First and Last Name
Student Date of Birth
Grade Level (in Fall)
Apartment, Suite, or Unit #
Parent/ Caregiver Information
Parent/ Caregiver First and Last Name
Alternate Phone Number
Emergency Contact Name
Secondary Contact 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.
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.
Camp T-Shirt Order
Adult Extra Large
Adult Extra Extra Large
Adult Extra Extra Extra Large
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.
Tuition for youth camp is $410. 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 is available if YBT is notified before June 1st. After June 1st, 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.
YBT Youth Summer Camp (Full Tuition)
YBT Youth Summer Camp (2nd Child Enrollment)
YBT Youth Summer Camp (3rd Child Enrollment)