Please Complete Separate Forms for Each Student

2017CAMP SHAKESPEAREREGISTRATIONFORM

Please complete separate forms for each student

STUDENT NAME:
☐ Male ☐ Female
PARENT/GUARDIAN NAME:
ADDRESS:
CITY, STATE, ZIP:
DAY PHONE: EVENING PHONE:
Parent/Guardian EMAIL: CAMPER DATE OF BIRTH: CAMPER AGE:
SCHOOL NAME AND ADDRESS:

CAMP SHAKESPEARE Ages 8-14 Tuition: $325.00 Camp day is Mon-Fri, 8:30 A.M. – 3:30 P.M.

I am paying: ☐ $325.00 OR ☐ $300.00for returning campers OR second student from same family

☐ BROOKSIDE 1 ☐ BROOKSIDE 2
June 5-16June 19-30
St. Andrew’s Episcopal ChurchSt. Andrew’s Episcopal Church
6401 Wornall Terrace6401 Wornall Terrace

Kansas City, MO 64113 Kansas City, MO 64113

Performance on the Festival Stage, June 17 Performance on the Festival Stage, July 1
☐ OVERLAND PARK ☐ LEE’S SUMMIT
June 12-23July 10-21

Unity Church of Overland ParkGOT Art Gallery
10300 Antioch Road18 SW 3rd Street

Overland Park, KS 66212 Lee’s Summit, MO 64063 Performance on the Festival Stage, June 24 Public performance on final day of camp

☐ SHAKESPEARE UNLIMITED ☐ SOUTH KANSAS CITY

July 24 – August 4 -For Returning Campers July 17-28

St. Andrew’s Episcopal Church Alexander Majors Barn
6401 Wornall Terrace 8201 State Line Road

Kansas City, MO 64113 Kansas City, MO 64114

Public performance on final day of camp Public performance on final day of camp

☐ WESTON

July 24-August 4

Weston United Methodist Church

533 Main Street

Weston, MO 64089

Public performance on final day of camp

HIGH SCHOOL/SPECIALITY CAMPS Camp day is Mon-Fri, 9:00 A.M. –3:00 P.M.

I am paying:☐ $440.00OR ☐ $415.00 for returning campersOR second student from same family

☐ SHAKESPEARE EXPLORATION ☐ SHAKESPEARE ALIVE
Ages 14-18Ages 8-18

June 12-30July 10-28
Grant Hall, UMKCGrace Church of the Nazarene

5228 Charlotte4300 Independence Ave

Kansas City, MO 64111Kansas City, MO 64124

Performance on the Festival Stage, July 1 Performance on final day of class

WILL’S PLAYERS Ages 5-8Tuition: $150.00 Monday – Friday 9:00A.M. –12:00P.M.

I am paying:☐ $150.00 OR ☐ $135.00for returning campers OR second student from same family

☐ Will’s Player’s South Kansas City ☐ Will’s Player’s Midtown

June 19-23 July 24-28

Alexander Majors BarnSt. Paul’s Episcopal Day School
8201 State Line Road4041 Main Street
Kansas City, MO 64114Kansas City, MO 64111

Performance on final day of class Performance on final day of class

☐Check enclosed. Make check payable to Shakespeare Education.

Please put camper name(s) on memo line.

Credit Card (Check type)☐Visa ☐MasterCard ☐Discover ☐American Express

Card #: Expiration: CVV#:

Amount: Signature:

I want to help other students attend camp! I included $ for the Floyd Walker Scholarship Fund. This amount is tax-deductible. Heart of America Shakespeare Festival is a 501(c)(3) not-for-profit corporation registered in Missouri.

MEDICAL/EMERGENCY INFORMATION:

List any medication(s) and dosage student is required to take:

List any physical challenges, special needs or health issues:

Parent/Guardian Name: Relationship to Student:

Emergency contact: Relationship to Student:

(if different from parent/guardian):

Emergency Phone:

WAIVER AND PERMISSION:

My child has permission to participate in the activities of Camp Shakespeare, Shakespeare Exploration, Will’s Players, Shakespeare Unlimited or Shakespeare Alive. I understand that I will be responsible for the cost of any emergency medical care that may be necessary for my child while involved in these programs, and hereby consent to such emergency medical care. I understand that, in the case of any medical emergency, the teaching artists will contact the emergency contact listed as soon as possible.

The Heart of America Shakespeare Festival and its employees are not responsible forthelossof,nor damageto,any personal property broughtby students to any classes, rehearsals, or performances.

I give permission to have photographs and/or videos taken of my child during the class, which may be

used for the Heart of America Shakespeare Festival’s promotional and archival purposes.

Student Name:

Parent/Guardian Signature: Date:

Questions? E-mail OR call 816-531-7728.

Please return completed Registration Form and payment to:

Heart of America Shakespeare Festival

Attn: Matt Rapport, Director of Education

3732 Main Street,

Kansas City, MO 64111

Email to