Randolph

Theatre Camp
REGISTRATION FORM Summer 2015
QUESTIONS? Contact Randolph Recreation Department 802-728-5433 x. 18 or rec@randolphvt.org
STUDENT NAME:

PARENTS/GUARDIANS NAMES

DATE OF BIRTH:

ADDRESS:

AGE:

CITY:

HOME PHONE:

PARENT/GUARDIAN E-MAIL ADDRESS:

CELL PHONE:

_______________________________________________

STATE:

ZIP:

________________________________________________________________________________
August 17th- August 21st
Monday- Friday 10:00am 12pm (grades K-9)

Total Tuition ....................................................................................................................................................................... $150

Required non-refundable deposit due upon registration ............................................................................................... $30
Balance due on August 10th, 2015 .................................................................................................................................. $120

Parents/guardian of enrolled campers must sign below agreeing to the Refund & Cancellation Policy.
REFUND & CANCELLATION POLICY:

**The tuition deposit is non-refundable.

**The tuition balance payment will become non-refundable as of the opening day of camp on August 14th, 2015
** There are no daily options.
By signing below I accept and agree to the Refund & Cancellation Policy of the Town of Randolph. I also hereby allow any
photography taken to be used in promotional materials for the Randolph Recreation Department.
I authorize the staff and volunteers of the Randolph Recreation Department to provide basic first aid or to call additional
medical care on my childs behalf in the event of an emergency, if I cannot be reached or when delay would be dangerous
to my childs health. I further agree to release the Town of Randolph and their staff and volunteers from any liability
connected with my childs participation in the 2015 summer programs.
Signature of students parent or guardian
______________________________________________________________________________________________________________________
PAYMENT INFORMATION:
Check made payable to Town of Randolph, Recreation Department
MAIL To: Town of Randolph, Recreation Department, 7 Summer Street, Drawer B, Randolph, VT 05060
www.randolphvt.org
Date Recd _______ Amt Paid $________ circle: cash / check # _________ Staff Initials _________
Please return to: Randolph Recreation Department, PO Drawer B, 7 Summer Street, Randolph, VT 05060