Winter Camp Workshops

YORKTOWN STAGE THEATRE WORKSHOPS
CAMP REGISTRATION FORM
Use separate form for each child.
WINTER SESSION
DEC 26-30
Mon-Fri 9:00am-3:30pm
$199.00
Total Amount: $
Discount Amount Applied: $
Child’s Name*:
Date of Birth*:
(Format:mm/dd/yyyy)
Age Today*:
Grade*:
Gender*:
BoyGirl
Name of Primary Parent/Guardian*:
Email Address*:
Address of Primary Parent/Guardian*:
Phone Nos. Primary Parent/Guardian*:
Name of Other Parent/Guardian:
Email Address:
Phone Nos. Other Parent/Guardian:
Prior YS Camper:
Child To Be Placed With (Optional):

Emergency Contact (to be called if Prime or Other Parent / Guardian cannot be reached):

Name*:
Phone*:

Release Statement*: I hereby release the Executive Director and all employees of YORKTOWN STAGE from all claims of liability for any damages or injuries which may be sustained while my child is in camp. I hereby give permission for my child’s photograph to be used in Yorktown Stage’s Summer Camp publications, and for advertising and promotions. I hereby authorize YORKTOWN STAGE to charge my credit card below referenced, if any, for any and all charges incurred by me, relating to the extended care of my child, either before care or aftercare.

Signature of Parent / Guardian*:
Date*:
(Format:mm/dd/yyyy)

RELEASE OF MINORS: All campers are released at the end of the camp day to parent / guardians.
NO CAMPER WILL BE ALLOWED TO LEAVE WITH A STRANGER.

My child can be released to the following people:

NAME:
PHONE:


NAME:
PHONE:

REFUND POLICY: If a person withdraws from a summer session prior to June 15 of the camp year, then the total fee, (less 25% for administrative costs), will be refunded. There will be no refunds for any person for any reason after June 15 of the camp year. The Camp Director and/or the Executive Director have the right to dismiss any child for behavioral problems. Money will not be refunded for days missed due to dismissal or illness.

NOTE: Your application cannot be processed unless completely filled out and signed. Your medical forms(s) must be submitted before the session starts. You will receive EMAIL confirmation of Registration. PLEASE remove spam filters. If not received, PLEASE call office at 914-962-0606.

Coupon Code:

Credit Card Information:

Card Type*:
Card Number*:
Expire Month*:
Expire Year*:
Sec. Code*: