Little Lakes 2013 TASC APPLICATION

Circle Preference:

SESSION ONE

or SESSION TWO

Name of camper ______________________________________________ Circle: Male or Female

Street
Address___________________________________________________________________________________
City/State/Zip______________________________________________________________________________
Home Phone ( )__________________Parent(s) Email ______________________________________________
Age _________ Birth date _____/____/____ Grade level (Fall 2013) ______School ______________________
Parent name (s) ____________________________________________________________________________
Mother contact phone (Day) _________________________ (Cell) ____________________________________
Father contact phone (Day) _________________________ (Cell) ________________________
EMERGENCY RELEASE INFORMATION
Emergency Contact (other than parent) Name _____________________________Phone (_____)____________
Health Insurance Carrier and Number ___________________________________________________________
Doctors name ___________________________________________Phone (_______)____________________
Please note all physical/medical conditions/restrictions of which our staff or medical personnel should be aware:

Please note any medications camper takes on a regular basis:

Please note allergies:

I give representatives of LITTLE LAKE THEATRE COMPANY permission to seek emergency medical
attention for ______________________________ in the event that I cannot be reached or until I am able to be
present.
_____________________________________________
__________________________________
Signature of parent/guardian
Date
For the camper to complete: I am interested in attending Theatre Arts Summer Camp because ______________
__________________________________________________________________________________________

One TASC t-shirt is included in every enrollment payment. Circle t-shirt size:
Small

Medium

Large

XLarge

PAYMENT INFORMATION Campers name __________________________________________

____ I have enclosed a check for $250.00. This represents payment in full for Session: One / Two.
____ I have enclosed a deposit of $25.00 to reserve space in Session One / Two. This deposit will be credited to
my enrollment fee. I understand my deposit is non-refundable. If camp is filled when Little Lake receives this
applicationthe deposit will be returned. I also understand that the full fee for camp is $250.00 and that Little
Lake must receive the remaining payment in full by the completion of the orientation meeting.
____ I have enclosed other payment of ____________________________________________
Camp fees are not refundable once the camp session has started.
Parent signature
______________________________________________________________________________
Parent name (Please print)
______________________________________________________________________________
CAMPERS and PARENTS: Please read and sign Camp Safety Sheet and submit it with your application or
bring it with you to orientation. If you are a returning camper who will not be attending the orientation, please
return the Safety Sheet no later than the first day of camp. Campers WILL NOT be allowed to participate in any
camp activities until Little Lake has received the completed the Safety Sheet.
Mail application and safety sheet to: TASC Little Lake Theatre 500 Lakeside Dr. South Canonsburg, Pa. 15317