Moving Image & Media Arts Camp RegistrationMoving Image & Media Arts Camp Registration Form Name of Camper*Age*91011121314Grade (entering)*5th6th7th8thOtherSchool (entering)Camp Choices & Registration FeesREGISTRATION PAYMENT* Acknowledgement of registration requirement Payment is required upon registration or, if paying by check, received in full at CATV by July 1st. (Please email info@catv8.org to submit a request for tuition assistance or waiver.)Select 1st Choice Camp from drop-downHandmade Cinema JULY 12-16Studio Production JULY 19-23On Location Production JULY 26-30Session(s) - 1st choice Morning - Regular Afternoon - Regular All-Day - Regular Morning - CATV service area Afternoon - CATV service area All-Day - CATV service area Select 2nd Choice Camp from drop-downHandmade Cinema JULY 12-16Studio Production JULY 19-23On Location Production JULY 26-30Session(s) - 2nd choice Morning - Regular Afternoon - Regular All-Day - Regular Morning - CATV service area Afternoon - CATV service area All-Day - CATV service area Select 3rd Choice Camp from drop-downHandmade Cinema JULY 12-16Studio Production JULY 19-23On Location Production JULY 26-30Session(s) - 3rd choice Morning - Regular Afternoon - Regular All-Day (Both) - Regular Morning - CATV area resident Afternoon - CATV area resident All-Day - CATV area resident Total $0.00 Payment Options (select)I will mail a check (instructions at confirmation)PayPal, or Credit/Debit (via Paypal guest checkout)I will email CATV a tuition assistanceContact & Medical InformationCamper's Summer Residence Address*Permanent Address (if different)Name of Primary Parent/Guardian* First Last Primary Parent/Guardian Email Address* Home Telephone for Primary Parent/Guardian*Cellphone for Primary Parent/Guardian*Work Phone for Primary Parent/Guardian*Name of Secondary Parent or Guardian First Last Secondary Parent/Guardian Email Address Cellphone for Secondary Parent/GuardianEmergency Contact Name*Emergency Contact Relation to Camper*Emergency Contact Cellphone*Emergency Contact Additional Phone*Emergency Contact Email Address*Name of Primary Medical Care Provider*Primary Medical Care Provider Phone*Dentist*Dentist Phone*Please list any allergies*What experience (if any) does your child have in film/video production or acting/performance?Please share anything else you'd like us to know about your child to help him/her have a positive experience at camp.Consent & Release of LiabilityConsent & Release of Liability* I agree to the Consent & Release of Liability policy.* You consent to your camper participating in all regular CATV (Community Access Television, Inc.) Camp activities, both on and off Hartford High School/HACTC grounds, and accept the fact that some of these involve inherent risks. By permitting your child to attend and participate in Camp activities, CATV and its agents, employees, and volunteers are released from any and all claims for damage arising out of injury to your child while participating in any and all activities including, but not limited to: video production (operating cameras, sound equipment, lighting, grip gear and props), acting/performance, arts and crafts, and digital editing programs. Such activities may occur on-site or off-site in Vermont or other states. * You consent to the use of photographs or video of your camper to be used in publications, news releases, online, and in other communications related to the mission of CATV. * You agree to inform us if your child is enrolled in an Individualized Education Program or 504 Plan, receives other special social-emotional or behavioral support, or has any medical issue that may impact their ability to engage in the camp environment or camp community. You consent to CATV contacting you and your child’s service provider(s) and/or professional(s) to develop a plan to help your child succeed at camp. * You understand that you are responsible for your camper’s medical expenses, including deductibles, and co-pays. You consent to emergency medical treatment for the camper if CATV, in its sole discretion, determines it to be necessary. In the event of a medical emergency, you consent to CATV contacting you and other emergency contacts whom you have provided. * You understand that your child is required to be vaccinated according to the Federal Centers for Disease Control (CDC) immunization guidelines AND Vermont Department of Health immunization schedules. Religious or philosophical exemptions are not accepted. Medical exceptions are only allowed for conditions established by the CDC or the Advisory Committee on Immunization Practices (ACIP). The medical exception must be submitted for individual shots in a signed statement from a licensed pediatrician which states: The physical condition or medical circumstances of the camper and which vaccines are contraindicated. Whether the medical exception is permanent or temporary. The expiration date, if the exception is temporary.How did you hear about camp?*CATV NewsletterValley NewsListservsFriendPromotional flyerRec DepartmentOtherCAPTCHA
