RICE P. A. C. HOME BASE
REGISTRATION FORM

This registration form is specifically for families interested in programming at New Covenant Faith Ministries in Henderson, NC. All other programming and registration inquiries should be sent to ricepacinfo@gmail.com or directly to your Host Organization Representative.

Consent

By completing this form and registration for your child, you agree to the following: I, the parent or guardian of the child, am registering and give permission for him/her to participate in the Rice Performing Arts Camp. To the best of my knowledge, my child is in good health and fit to participate in an active program. I understand that there may be inherent risk, and agree to hold harmless Rice Performing Arts Camp, its employees, agents and volunteers, as well as the owners and managers of the facility used, for any loss, damage, injury, disease or death resulting from these activities. In case of emergency when I cannot be reached, I give permission to a licensed health care provider, selected by Rice Performing Arts Camp or the facility supervisor, to secure medical treatment including hospitalization, injections, anesthesia and/or surgery as may be deemed necessary for any child I am registering. I also understand and agree that I am responsible for all expenses incurred in the event of such an emergency. I further give permission for my child(ren)'s name and/or likeness to be used by Rice Performing Arts Camp and/or the facility supervisors for publicity, advertising, etc.

Child's Name

First Name

Last Name

Child's Grade (next school year)

This program serves rising 1st-8th graders.

Child's Date of Birth

YYYY

Child's Gender

Parent/Guardian's Name

First Name

Last Name

Parent/Guardian's Best Phone Number

(###)

###

####

Parent/Guardian's Best Email Address

Residential Address

Where will you and your child be commuting from?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Experience

Does your child have any theatrical (acting, singing, dancing) experience? If so, please specify.

T-shirt Size

Please select one.

Does your child have any scheduling conflicts?

Home Base Programming takes place June 20th-25th. Please list any and all dates on your schedule that may conflict with programming dates.

Do you have sufficient transportation to get your child to and from programming on time?

Children should arrive no later than 9:20am and be picked up no later than 3pm. Transportation cannot be provided by Rice P.A.C. at this time.

Does your child need ANY special accommodations?

Allergies, Food Allergies, Prescription Medicine, etc.

Daily Check-Out

At the end of each day, your child must be signed out by an authorized adult. Please list the name(s) of the adult(s) who are authorized to pick up this child from programming. If no names are listed in the space below the child will be released only to the parent/guardian who signs this form.

Emergency Contact 1

Please include Name, Phone Number, and Relationship to the Child.

Emergency Contact 2

Please include Name, Phone Number, and Relationship to the Child.

Registration is not complete until a representative has reviewed this form and all registration fees have been paid in full.

Following submission, this registration form will be reviewed and an invoice for your registration fees will be sent to the provided email. Early Registration is not eligible for sponsorship or deposits, but does guarantee registration for Summer 2022 Programming.

I will need Registration Fee assistance or a full sponsorship.

Although funding is sometimes available to assist parents with registration fees or to completely sponsor a Rising performer in need, it is not guaranteed and is subject to an additional application and interview process. If you are in need of this, please specify below and you will be contacted by a Rice P.A.C. Rep.

I have read, understand, and agree with the terms of this registration form.

By signing this registration form you also authorize Rice P.A.C. to take photos/video footage of your child for promotional purposes only.

RICE P. A. C. HOME BASE REGISTRATION FORM

RICE P. A. C. HOME BASE
REGISTRATION FORM