General Information Medical Information Clearances Fees Payment Name General Information CONTACT INFO OF PERSON FILLING OUT THIS FORM First Name * Last Name * Email * Phone Number * Address * City * State * Select a State/ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Employer * Occupation * Employer City * Employer State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana IAIowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Employer Zip Code * Church Name * Youth Pastor Name Church Address, City, State * ADDITIONAL PARENT/CONTACT INFO Other Parent Name Other Parent Phone Other Parent Email PARTICIPANTS Select a Camp: Camp Winter Camp - Dr. Seuss How many members of your household are participating in this workshop? * One Student Two Students Three Students Four Students Participation Fee Calculation Participation Fee: $ Member 1 Legal Name * Member 1 Cell (opt) Member 1 Birthdate * Grade * select grade Preschool (3-5year old) Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade School Name (M1) * School City/State (M1) * Music Teacher Name (M1) * Participant Medical Information Primary Physician * Physician Phone Number * 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: $ First Name On Card * Last Name On Card * Address Line 1 * Address Line 2 City * Zip Code * State/Province * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Country * ALBANIA ALGERIA ANDORRA ANGOLA ANGUILLA ANTIGUA & BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA & HERZEGOVINA BOTSWANA BRAZIL BRITISH VIRGIN ISLANDS BRUNEI BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CHAD CHILE CHINA COLOMBIA COMOROS CONGO - BRAZZAVILLE CONGO - KINSHASA COOK ISLANDS COSTA RICA CÔTE D’IVOIRE CROATIA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA GABON GAMBIA GEORGIA GERMANY GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUATEMALA GUINEA GUINEA-BISSAU GUYANA HONDURAS HONG KONG SAR CHINA HUNGARY ICELAND INDIA INDONESIA IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KUWAIT KYRGYZSTAN LAOS LATVIA LESOTHO LIECHTENSTEIN LITHUANIA LUXEMBOURG MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE NAMIBIA NAURU NEPAL NETHERLANDS NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORWAY OMAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN ISLANDS POLAND PORTUGAL QATAR RÉUNION ROMANIA RUSSIA RWANDA SAMOA SAN MARINO SÃO TOMÉ & PRÍNCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH KOREA SPAIN SRI LANKA ST. 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