Summer Camp Registration and Emergency Contact Card Participant Name: ______________________________________________ Grade (completed): ________________

Date of Birth: ____/____/____

School: ______________________ Tshirt Size__________

Street Address: ___________________________________________City_______________ Zip_____________ Mother’s Name___________________________

Father’s Name_______________________________

Home Phone _____________________________

Home Phone_________________________________

Work Phone _____________________________

Work Phone_________________________________

Cell Phone ______________________________

Cell Phone __________________________________

Email__________________________________

Email_______________________________________

Pediatrician’s Name_______________________ Phone #_________________ Hospital Pref:_______________ Allergies:____________________________________________________________________________________ In case of Emergency, I give Permission for either of the following people to be contacted and/or to pick up my child from the theater. 1) Name________________________________Phone____________________Relationship_____________ 2) Name________________________________Phone____________________Relationship_____________

Please check all the following that apply: □

Introduction to Acting

July 5 – July 8

8:30am – 11:30am

$140

□

Intro to Theatre Design

July 5 – July 8

12:00pm – 3:00pm

$140

□

Improv for Teens

July 11 – July 15

8:30am – 11:30am

$175

□

Theatrical Dance

July 11 – July 15

12:00pm – 3:00pm

$175

July 18 – July 29

8:30am – 11:30am

$350

□ One Act Workshop (2 weeks) [Performance Included]

Additional Notes: • Programs are designed for students in 7th - 12th grades at all levels of experience • If students are staying a Full Day (8:30am-3pm) they must bring lunch, as it is not provided • Before Care and After Care available if scheduled in advance (additional fees may apply). •

Please make all checks payable to “Pegasus Theater”

• Receive a 5% discount if booking 2 Programs, 10% if booking 2, 15% for 3 or more! • Siblings receive 10% discount on all programs! • To register, return form and 20% non-refundable deposit to: Pegasus Theater Christian Brothers Academy 850 Newman Springs Rd. Lincroft, NJ 07738 • Full payment due before first day of camp. • Please feel free to call 732-907-PEGA (7342) or email [email protected] with any questions.