YES! I WANT TO MAKE TV THIS SUMMER!
Student’s Name: __________________________________________________
Address: ________________________________________________________
e-mail: __________________________________________________________
Phone: ( )___________ School: ____________________________________
Birth Date: ___/___/_____ Grade: _________ Sex: _________
Mother’s / Guardian's Name: __________________________________________________
Work Phone: ( )___________ cell: _________ e-mail: ________________
Father’s / Guardian's Name: ___________________________________________________
Work Phone: ( )___________ cell: _________ e-mail: ________________
Emergency Contact: _________________________ Phone: ( )____________
I authorize my child to participate in all camp activities, including leaving EBMC facilities while under adult supervision.
I agree that all media produced is exclusive property of EBMC, all rights reserved.
ILLNESS, ACCIDENT, OR INJURY: In the event of a serious illness or injury, I authorize emergency medical care for my child.
I wish my child to be taken to the nearest Emergency Medical Facility, and the following doctor notified:
Doctor’s Name: ____________________________ Phone: ( )______________
Insurance Company and Policy Number: ________________________________
Parent(s) / Guardian(s) Signature: _______________________________________________________ Date: ______________
Summer Teen Media Camp
2012 – July 9-28, 2012
Time: Monday through Friday, 10:15 AM to 2:15 PM
Cost: $800.00 per session
Ages: 13 - 17
Cancellation/Refund Policy: No Refunds
All production and classes located in Berkeley's Downtown Arts District at: