Camper Name _________________________________
Camper Address _______________________________
City _____________________ Zip _________________
Parent/Guardian Name _________________________________
Address ____________________________________________
Home Phone ________________________________________
Cell Phone __________________________________________
Email Address for confirmation __________________________
School currently enrolled in ______________________________
Grade ________ Music/Drama Instructor _________________
Favorite Class _______________________________________
Insurance Information and Release to Participate:
______________________________, has my permission to participate in the Memorial High School Theatre Camp on Saturday,
October 2, 2010 from 9am until 2 pm (and in the matinee performance of "You're a Good Man, Charlie Brown" at Memorial High
School. I understand that all students involved are subject to school rules, including those listed in the Student/Parent
Handbook found on the SBISD Website which include dress and conduct while at camp, and that failure to abide by these
rules and regulations may result in disciplinary action and removal from the camp and/or performance. Failure to follow
these regulations may result in a student sent home immediately.
I hereby release the Spring Branch Independent School District (SBISD) and the Board of Directors of MHS Theatre Booster
Club Inc, all its supervisors, employees, volunteers and/or representatives from any and all liability and/or claims and/or
cause of actions individually or collectively, for any damages or injuries which might be received during this activity, except
for those which SBISD, its supervisors, employees, volunteers, and/or representatives have effective insurance coverage but
only to the extent of such insurance coverage.
I/We, being the parent or leagal guardian of _______________________, a minor, do hereby appoint an agent of SBISD from
Memorial High School to act in my/our behalf in authorizing emergency medical, dental, or surgical care and hospitalization
for the minor named during a period of my absence. This authorization is given with my/our understanding that attempts
will be made to contact me/us prior to the administration of treatment for any non-life-threatening situation/condition utilizing
the contact information that I/we have provided.
In order to participate in this camp, each student must have written permission from the parent/guardian.
_________________________________________________________
Signature of Parent/Guardian and phone number
_________________________
Date
Special health or dietary needs:
In case of emergency in parent/guardian cannot be reached, please contact:
________________________________________________________
Adult Name and phone number
