Campers Name:
First Name: Middle: Last:
Gender: Male Female Birth Date: Grade Fall 2012:
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 26 - JUNE 2
  WEEK 2 ........... JUNE 2- JUNE 9
  WEEK 3 ........... JUNE 9 - JUNE 16 		  WEEK 4 ........... JUNE 16 - JUNE 23
  WEEK 5 ........... JUNE 23 - JUNE 30
  WEEK 6 ........... JUNE 30- JULY 7 		  WEEK 7 ........... JULY 7 - JULY 14
  WEEK 8 ........... JULY 14 - JULY 21
  WEEK 9 ........... JULY 21 - July 28  
ART WEEKS (Sunday to Sunday) - I wish to enroll for the following: CHESS WEEK (Sunday to Sunday)
  WEEK 1 ........... MAY 26 - JUNE 2
  WEEK 2 ........... JUNE 2 - JUNE 9 		  WEEK 4 ........... JUNE 16 - JUNE 23
  WEEK 5 ........... JUNE 23 - JUNE 30 		  WEEK 3 ........... JUNE 9 - JUNE 16
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:         *(never played an instrument)
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.
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Music Camp, Summer Music Camp, Band Camp, Art Camp, Chess Camp,
Jemez Music Camp, Orchestra Camp, Summer Camp