The Alliance for the Arts, Ltd.                                                                             2010  REGISTRATION2010

500                        Bland St. Bluefield, WV  24701                                                                              

                304.                      325.8000

                                              Camper Information:

                Last                       Name_______________________, First__________________________ Age____   Date of Birth__/__/____ Sex M  F  (circle one)

                                              Address_______________________________________________________________________________________________________

                                              Mother’s Name________________________________ Father’s Name___________________________________________________

                                              Home Tel. No.  (    ) __________________ Emergency Contact No. (   )___________________________________________________

                Email                    Address________________________________________ Cell #__________________ cell #__________________________________

                                              School (Sept 2010) _________________________________  Grade Level (Sept 2010)______________________________________

                                               Does  your child have any physical, mental or medical (includes allergies) condition of which we should be aware?   ____________________________________

                                             If yes, please identify:___________________________________________________________________________________________

                                            Total Fee: $125.00

                                            Deposit: Non-refundable $50.00 due NOW    make checks payable to: The Alliance for the Arts, Ltd.

                 Balance  Due by:  July 19, 2010

               I authorize The Alliance for the Arts, Ltd. to use photographs, recordings, videos, etc. taken of my child in camp and at the public performance.  Yes____ No____  (please initial)

         Signature of Parent or Guardian X____________________________________ Date:_________________

             Instructions:   Please Sign and complete this form.  Mail or Drop off to;

             The Bluefield Area Arts Center

             ATTN:  Cameron Burton

             500 Bland St. Bluefield, WV  24701

        Camp Details available at www.summitplayers.com or by calling 304.325.8000