2015 MOVIE MAKERS

CAMP REGISTRATION FORM

Monday, July 20 Thursday, July 23, 2015
9 am 12:30 pm
Haverhill Community Media, 60 Elm St, Haverhill, MA 01830
Contact: (978) 372-8070 or lparis@haverhillcommunitytv.org
REGISTRATION MUST BE RECEIVED IN FULL BY JUNE 30 TO SECURE A PLACE IN CAMP.

Todays Date: ________________________ Date Received (Office Use): _______________________

Childs Name: ____________________________________ Date of Birth: _______________________
Address: ________________________________________ City, State, Zip: _______________________
Daytime Telephone: ______________________________ Cell: ________________________________
Email address: ________________________________________________________________________
Please list areas of interest in order of preference: (i.e. acting, directing, screenwriting, videography):
1. ______________________________________ 2. ________________________________________
3. ______________________________________ 4. ________________________________________

Emergency contacts (please print):

Emergency Contact 1:
Name: ________________________________
Relationship: _________________________
Address: _____________________________________ Phone: _________________________
Emergency Contact 2:
Name: ________________________________
Relationship: _________________________
Address: _____________________________________ Phone: _________________________
Pick-Up Information:
Name of person who will be picking up camper: ___________________________________
Relationship: ____________________________ Phone: ______________________________

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PARENT/GUARDIAN CONSENT FORM

Childs Name: ________________________________ Date of Birth: ___________________

Before camp begins, a copy of each childs insurance card must be provided.
If campers have a preexisting medical condition, a doctors note is required.
If any camper requires medication between the hours of 9 am and 12:30 pm, parents will
need to return to administer the medication to their child.

Childs Physician Information:

Physician Name: ________________________________ Phone #: ______________________________
Insurance Carrier: ______________________________ Member ID: ___________________________
Please list any allergies and/or medical conditions here: _____________________________________
____________________________________________________________________________________
WAIVER/MEDICAL RELEASE: Upon registering and participating in this activity, I hereby
release Haverhill Community Media, their employees and any person officially connected with
their activities from liability or damages to the person or property arising from participation in
or my presence at this activity. Further, I allow any first aid deemed necessary in case of injury.
I understand and agree that Haverhill Community Media reserves the right to suspend a child
participant from an activity if that child displays a serious behavior problem that cannot be
effectively managed by program personnel.
PHOTOGRAPHY RELEASE: I hereby consent without further consideration or compensation to
the use of all photographs and video taken for broadcast TV and Internet distribution and
usage. I hereby grant permission to use any photos taken for this program without
compensation for publicity use.

Campers Signature: _______________________________________________________

Parent/Guardian Name (Print): _______________________________________________
Parent/Guardian Signature: __________________________________________________
Date: ____________________________

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