REGISTRATION FORM (please print)

July 27 - 31, 2009 | 9 – noon | at First Federated Church

Child’s Name: Child’s Age:

Address: Apt. No.:

City/State: Zip:

Home Phone: Work Phone:

Cell Phone: Child’s Date of Birth:

E-Mail: School Grade Completed:

Mother’s Name: Father’s Name:

Emergency Contact Name: Emergency Contact Phone:

+Allergies or Other Medical Conditions We Need to Know of:

+Note: We are a peanut-free zone.

Others Persons You Give Permission to Release Your Child to:
Relationship(s):

Children will not be released to others unless listed by parent.

Circle Shirt Size: YS YM YL AS AM AL AXL
(6-8) (10-12) (14-16)
Please complete Medical and Liability Release on the back of this form.

Each child attends only one workshop for the week.

Please see detailed descriptions of workshops to Workshop Choice No. (1, 2, 3)
help you and your child determine appropriate Drama __________
selections (some age and ability restrictions apply). Media (limited #) __________
Please indicate your first, second, and third choices Set Design __________
for camp workshops. All effort will be made to place
your child in the first choice if possible.
Vocals __________
Dance __________

CAMP REGISTRATION FEE IS $25. AFTER JUNE 15rd: $35.

Please make checks payable to First Federated Church.
 Medical and Liability Release

Our goal is to provide a fun-filled and accident-free week of camp; however, no activity is without the possibility of
unforeseen hazards which could result in injury. As a parent or guardian, please instruct your child in the importance of
conduct which will insure safety and an enjoyable time while participating in A.W.E.SOME Arts Camp.

By signing this form, you, as parent, guardian, or other responsible party, agree to assume the risks and hazards which
are inherent in this kind of activity. You also agree to absolve and hold harmless the sponsoring organizations and their
representatives for damage, loss or injuries to the child for whom you sign.

I give my child, ________________________________________, permission to participate in this activity, and give my

permission to the leaders of this creative arts camp to authorize any treatment deemed necessary by a licensed physician
due to accident or illness during this activity.

I also give my permission for the use of any photo or likeness of my child to be used by the sponsoring organization for
their use in promotional materials.

Signature of Parent or Guardian _____________________________________________

Date _________________

Co-hosted by Des Moines First Assembly and First Federated Church

279-9766 255-2122