2022 Winter Break Camp

General Information

CONTACT INFO OF PERSON FILLING OUT THIS FORM

ADDITIONAL PARENT/CONTACT INFO

PARTICIPANTS

Select a Camp:

Participant Medical Information

The health history and other information requested above are complete and accurate to the best of my knowledge. The participant herein described has permission to engage in all prescribed activities except as noted above I hereby grant authorization and consent for Harrisburg Christian Performing Arts Center (HCPAC) personnel to administer general first aid treatment for any minor injuries or illnesses experienced by myself/my minor child. If the injury or illness is life threatening or in need of emergency treatment and I am unable to authorize medical care, or, in the case of a minor, I, the parent/guardian cannot be reached, I grant authority to HCPAC personnel to seek medical attention on my behalf or that of my child listed above, to summon any and all professional emergency personnel to attend, transport, and treat myself/my minor child and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses resulting from such care.

Child Clearances

Adult performers, age 18 years and over, must have the following forms on file to participate in workshops:

Act 34 – Criminal Record Check from the Pennsylvania State Police (FREE for volunteers)

Act 151 – Child Abuse History Clearances from the Department of Human Services (FREE for volunteers)

Act 114 – FBI Fingerprint Clearance (cost is $27.50) or Resident Disclosure Statement. Fingerprint Clearance is required if you have NOT been a continuous resident of PA for the last 10 years. If you have lived in PA for 10 consecutive years, you can submit the Resident Disclosure Statement

Contact HCPAC at [email protected] for help in filling out these requirements.

Participation Contract/Fees

PARTICIPATION CONTRACT

Please download and read the HCPAC Participation Contract before answering the questions below.

Download HCPAC Participation Contract

PAYMENT