Register

THEATER IN THE WOODS VT CAMP
Weekdays June 29 - July 10 (ages 7-11)
OR
July 13 - July 24, 2019 (ages 12-16)

Tuition and Payment information

The tuition for two weeks of camp is $550*
This includes daily delicious snacks and lunch.
A deposit of $200 submitted with this form holds your place in the camp. We happily accept installments of payments.
The balance is due June 25th, 2019.

SCHOLARSHIPS AVAILABLE!

* If you are a Rutland County resident, you may apply to The Hayes Foundation for a needs-based financial grant to assist with the tuition. www.thehayesfoundation.org/forms---info.html

!! IMPORTANT DEADLINE CHANGE: Hayes applications are no longer rolling but considered on a quarterly basis. The applications take three weeks for consideration. APRIL 1 and JUNE 1 are the pertinent deadlines for this camp, with decisions the third weeks of those months.

* If you live in Poultney, email us for information on scholarship assistance: theaterinthewoodsvt@gmail.com

* If you live in Tinmouth, you may apply to the Tinmouth Community Fund to assist with the tuition. The 2019 deadline is in APRIL.

* If you live in none of the above and need some assistance, write to us here: theaterinthewoodsvt@gmail.com

Although we have Pay Pal for your convenience, we incur fees with its use. Our preference is that you print the PDF form below this box and send it to us with your check to:
Theater in the Woods Vermont Co.
72 Sundog Lane, Middletown Springs VT 05757

QUESTIONS?
Call Melissa at 802-235-2050

tiw_registration_and_med_form_2019.pdf
File Size:	111 kb
File Type:	pdf

Download File

Alternatively, you may fill out the form below and use Pay Pal.

EMERGENCY AND MEDICAL RELEASE FORM

* Indicates required field

Camper's Name *

First

Last

Camper's age *

School and grade *

Parent or guardian *

First

Last

Parent or guardian *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Phone Number *

Email *

Emergency Contact Information - three contacts are required:

Name *

First

Last

Phone Number *

Name *

First

Last

Name *

First

Last

Phone Number *

Please list those people in addition to parents/guardians who are permitted to pick up your child:

Alternate Pickup/Release *

MEDICAL RELEASE INFORMATION

INSURANCE POLICY NAME *

INSURANCE CONTACT Phone Number *

INSURANCE POLICY ID # *

Primary Physician Name *

Primary physician address *

Phone Number *

Please list any medical problems, including any that require maintenance medication (i.e. diabetes, asthma, seizures) *

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? No/Yes. If Yes, explain: *

Is your child allergic to any type of food or medication? No/Yes. If Yes, explain: *

Does your child require a special diet? Yes/No. If YES, explain: *

Please list any other allergies (insects, seasonal/environmental, animals, asthma); describe reaction and management: *

Does your child need an EPI-Pen? No/Yes. If Yes, describe type of allergic reaction, including signs and symptoms of distress: *

Any medication to be self-administered or given by us at camp? Please specify by a written doctor's order with Name of drug and Dosage Frequency *

By checking these boxes below, I hereby give permission to give my child over the counter medications according to standard dose:

Tylenol *

Ibuprofen *

Benadryl *

Other, Please specify *

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

Does your child have any special needs - medical, emotional, learning? Provide as much detail as possible. *

Please indicate (or call us at 802-235-2050) any situations inside or outside of camp that may affect your child's behavior or attitude: *

RELEASE FORM

The majority of Theater in the Woods activities take place outside, with exposure to risks normal in outdoor activity. We will safeguard against normal foreseeable risks. At the same time, accidents can occur during the everyday course of events, and it is impossible for us to insure ourselves adequately against such occurrences. Therefore we ask you to take responsibility for providing adequate health insurance for your own child, and that you sign a waiver agreeing to indemnify us for any medical expenses. Your insurance information provided above enables reimbursement to be made for any medical care needed by your child in the duration of our day camp. In case of an emergency, and if a family physician cannot be reached, by checking the box below I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

Check Box *

I have read and agree to the terms above.

By checking the box below, I agree to hold Theater in the Woods Vermont blameless for any accident or injury which may occur to my child during the course of the camp, except in the case of gross or willful negligence, and I agree to indemnify Theater in the Woods Vermont against medical claims which may arise from my child’s illness, accident or injury.

Check Box *

I have read and agree to the terms above.

PHOTOGRAPHY and TRANSPORTATION

I hereby give permission for my child to be photographed during Theater in the Woods Camp. I understand the photos will be used to keep a journal of activities, to share in reports to our supporters, and for promotional purposes including flyers, brochures, and on the internet. I understand that although my child's photograph may be used for advertising, his or her identity will not be disclosed. *

I hereby give permission for the transportation of my child for Theater in the Woods activities by modes of transportation agreed to by the camp directors. *

TUITION PAYMENT

Tuition is $550. I agree that I will use the payment button below to pay the full fee or a deposit of $200 upon submission of this form. I agree that I will pay the balance of $350 due by June 25, 2019. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. *

I agree to the tuition payment terms.

Electronic Signature *

First

Last

Submit

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Theater in the Woods Vermont, L3C
72 Sundog Lane
Middletown Springs, VT 05757
theaterinthewoodsvt@gmail.com
802-235-2050