2022 Winter Break Camp – The Harrisburg Christian Performing Arts Center

December 26-30, 9am-4pm

It goes without saying that Dr. Seuss and his genius nonsensical books have magic to them. In all his wonderful weirdness, the acclaimed children’s author shares wisdom and lessons on self-acceptance, love and positivity. All the while, making up words and breaking all the rules of grammar.

Students in grades K-8 are invited to participate in Winter Camp 2022 as the charm and wit of Dr. Seuss will be alive on the Harrisburg Christian Performing Arts Center stage.

Winter Camp 2022 will be held Monday thru Friday, December 26-30, from 9AM – 4PM each day. A free camp showcase will be held for friends and family on Friday afternoon at 4PM.

Students will not only be cast in a charming Dr. Seuss Showcase but they will work together to construct set pieces and props, create their costumes, analyze the wisdom of Dr. Seuss, learn that it’s good to try new things (even green eggs and ham) and discover that it’s just plain silliness to judge people by their appearance rather than by their character.

Camper Participation Form
Childcare/Class Reimbursement Form

General Information
Medical Information
Clearances
Fees
Payment

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General Information

CONTACT INFO OF PERSON FILLING OUT THIS FORM

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ADDITIONAL PARENT/CONTACT INFO

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PARTICIPANTS

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Winter Camp – Dr. Seuss

How many members of your household are participating in this workshop? *

One Student

Two Students

Three Students

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Participation Fee Calculation

Participation Fee: $

Member 1 Legal Name *

Member 1 Cell (opt)

Member 1 Birthdate *

Grade *

School Name (M1) *

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Music Teacher Name (M1) *

Participant Medical Information

Primary Physician *

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Health Insurance Carrier *

ID/Policy Number *

Group Number *

Food/environmental allergies

Allergies to medicine and what kind of reaction it causes

Medical, Psychiatric & Behavioral Diagnosis

Explain Conditions (e.g., how well controlled, what is being done to treat, what we would need to tell EMTs in an emergency)

Current medications and what they are prescribed for

Is there any other Information about the participant that we should know in seeking to best minister to his/her needs at HCPAC?

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.

Medical Info Accurate

I agree.*

Electronic Signature *

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 Fee Net

Total Cost: $

PARTICIPATION CONTRACT

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

Download HCPAC Participation Contract

Contract Read

I agree.

I have read the Production Rehearsals, Policies and Promises of HCPAC and have reviewed them with all student members in my household. I/we promise our commitment to faithfully uphold the guidelines set forth. I/we acknowledge the failure of myself or my student members to follow through on any of these promises may jeopardize my/our involvement in this or subsequent productions.

Indemnify

I agree.

I shall indemnify and hold HCPAC harmless from any liability imposed upon HCPAC, adjudicated or otherwise, by virtue of any personal injury, illness or property damage arising from any use of the premises on the Harrisburg Christian Performing Arts Center by me, my agents and invitees, or by any acts done thereon by me, my agents and invitees, including court costs and counsel fees.

Media Release

I agree.

Media Release Authorization: I understand that by participating in the programming at Harrisburg Christian Performing Arts Center, I give Harrisburg Christian Performing Arts Center my permission to use a photograph or video of me/my child publicly to promote the Harrisburg Christian Performing Arts Center. I understand that the images may be used in print publications, online publications, presentations, websites, t-shirts and social media. I understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

PAYMENT

Total

Total Due: $

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Expiration Date *

Card Type *

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2022 Winter Break Camp

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