REGISTRATION FORM Spring/Summer Camps 2020


Parent/Guardian (if under 18) Parent/Guardian 2


Do both parents live in same household? Date of Birth (if under 18)


/ /


EARLY MEMBER REGISTRATION accepted starting 1/25/2020. All other orders accepted starting 2/1/2020.


Become a member of the Flynn at any time! Join online, by phone, in person, or on this form.


Relationship to Student Relationship to Student


Student’s Name Grade entering Sept. 2020


 I am new to the Flynn  I am a returning student Street


Daytime/Work Phone


Student’s Cell (if applicable) Email (required)


Evening Phone Student’s Email


YES! I’d also like to receive:  Emails about Flynn classes & camps  Emails about Flynn performances I give the Flynn permission to reproduce photos or video images in which I or my child appear.  Yes  No


 I give the Flynn permission for my child to go on short, chaperoned trips in and around the Flynn (if under 18).  I give the Flynn permission for emergency contacts to pick up my child (if under 18).  My child may travel home independently (if under 18).


How did you hear about camps at the Flynn? Summertime Jazz students: What is your preferred instrument?


List other instruments you play Years played: Years played: City Cell Phone School Zip


Please list a non-parent emergency contact IN ADDITION TO PARENTS LISTED ABOVE. (Adult students need to do this too!)


Name Relationship Phone


NOTE: If your child has any allergies or other health concerns, or if you have any information to share with the instructor that will help your child be most successful in camp, please attach a separate sheet with details.


YOUR SIGNATURE ACKNOWLEDGES YOU HAVE READ AND ACCEPT THE FOLLOWING:


“I understand fully that even after responsible precautions have been taken, camp activities may involve hazards for which the Flynn Center cannot be held responsible. In the event that I (or my child) become ill or injured during a camp, I authorize staff to seek emergency care. In signing below, I certify that I (or my child) am covered by health and accident insurance or Medicaid and that in the unlikely case of an accident, I will provide the Flynn Center with the name of the carrier and the policy number.”


Signature (Parent/Guardian if under 18)


Date 13


CUT AND RETURN WITH PAYMENT INFO


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