Curious Place Theatre Summer Camp Registration Curious Place Registration Form Curious Place Summer Camps* SPLASH! Camp July 17-21, 2023 MYTHICAL ADVENTURES! Camp July 31- Aug 4, 2023 FANTASTICAL PLACES! Camp Aug 21-25, 2023 Be sure to complete the payment information as well. Student Name* First Last Age* Grade 2022/23* Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Parent/Guardian Name* First Last Primary Email* Enter Email Confirm Email Primary Parent/ Guardian Phone (primary #)*Primary Parent/ Guardian Phone (second #)Primary Parent/Guardian Relationship to Student* Emergency Contact (other than Primary Parent/Guardian)Name* First Last Emergency Contact Phone*Emergency Contact Email Emergency Contact relationship to student* I give Spruce Peak Arts permission for emergency contact to pick up my child.* Yes No Please list below any adults that have your permission to pick up your child :*Does your child have any allergies, medications or special health needs?* Yes No Students who would be on an IEP needing one-on-one support, must provide their own aide.If yes, please explain....Consent for medical care: I understand fully that even after responsible precautions have been taken, class activities may involve hazards for which Spruce Peak Arts cannot be held responsible. In the event that my child become ill or injured during time at Spruce Peak Arts, I authorize staff to seek emergency care.* I agree to seek medical care if necessary.Medical Insurance*I certify that my child is covered by health and accident insurance or Medicaid and that in the unlikely case of an accident, Spruce Peak Performing Arts Center can share the name of the carrier and the policy number with health care provider provided.Name of CarrierPolicy Number I give Spruce Peak Arts permission to use a camper’s photograph or other media for display on the Spruce Peak Arts website or inclusion in Spruce Peak Arts publications.* Yes No (we respect your wishes if you do not grant permission) T-shirt Size*What size t-shirt does your camper wear? Youth-Small Youth-Medium Youth-Large Youth-X Large Adult- X Small Adult- Small Adult- Medium Adult- Large Adult -X Large Is there anything else we should know about your child to make this experience successful?Thank you for registering! 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