Campers Name:
First Name: Middle: Last:
Gender: Male Female Birth Date: Grade Fall 2010:
Address:
City: State: Zip:
Phone: Bus. Phone:
Email:
Med. Ins. Co.: Policy #:
Family Dr: Dr. Phone:
Last Tetanus: Hospital:
Any condition requiring attention: (allergies, etc.)
I authorize emergency medical treatment and/or hospitalization if necessary for this camper. (typed/signed name signifies authorization)Parent/Guardian Signature:

Wk 1 2 3 4 5 6 7 8 9 AC
Chk # ______________
Deposit ____________

Cam Inst ___________

     SCH
     TK         STAFF

     CIT       CON

     HCIT     HCON
FEE ________________
DEP _______________
BAL _______________
INST _______________
AA ________________
P _________________
T-S ________________

LT _________________

Total _______________
MUSIC WEEKS (Sunday to Sunday) - I wish to enroll for the following:
  WEEK 1 ........... MAY 30 - JUNE 6
  WEEK 2 ........... JUNE 6 - JUNE 13
  WEEK 3 ........... JUNE 13 - JUNE 20 		  WEEK 4 ........... JUNE 20 - JUNE 27
  WEEK 5 ........... JUNE 27 - JULY 4
  WEEK 6 ........... JULY 4 - JULY 11 		  WEEK 7 ........... JULY 11 - JULY 18
  WEEK 8 ........... JULY 18 - JULY 25
  WEEK 9 ........... JULY 25 - AUGUST 1  
ART WEEKS (Sunday to Sunday) - enroll me the week(s): CHESS WEEK (Sunday to Sunday)
  WEEK 1 ........... MAY 30 - JUNE 6
  WEEK 2 ........... JUNE 6 - JUNE 13 		  WEEK 4 ........... JUNE 20 - JUNE 27
  WEEK 5 ........... JUNE 27 - JULY 4 		  WEEK 3 ........... JUNE 13 - JUNE 20
1st Choice Week #: Arrival/Departure Dates: 2nd Choice Week #: Arrival/Departure Dates: Art Camp - Art Material fee $35 per week
Chess Camp - Novice Intermediate Advanced
Music Camp - instrument rental from camp - $25 per wk
Instrument I will play:
Beginner Intermediate Advanced
 I am interested in Transfer class
( Piano Guitar Band Orchestra)
Departure Transportation: Parent Guardian Other     Person assuming responsibility:
If person not designated here takes children home or away from camp, they must sign out in the office.
DEPOSIT FEE: ONE WEEK $200, TWO WEEKS $400 WILL SECURE REGISTRATION
One Half of this deposit will be refunded if you do not attend camp.
Please print and fill out, mail in (see address at top of form) or submit this form here.
©2010 Hummingbird Music Camp, Inc. Website Design by Terry V Henderson
Music Camp, Summer Music Camp, Band Camp, Art Camp, Chess Camp,
Jemez Music Camp, Orchestra Camp, Summer Camp