Summer Camp 2023 Registration Form

Please complete the form below. If you have any questions, contact info@birthplaceofcountrymusic.org or call 423-758-1927

Summer Camp - 2023 Registration Form

Date*
MM slash DD slash YYYY
Which week are you registering your child for:*
- June 19-23, 2023 (Beginner)
- June 26-30, 2023 (Intermediate)
Camper's full name*
Name camper wishes to be called*
Name of Person Submitting Payment for Camp*
First Last
Camper date of birth*
Grade*
T-shirt size*
Does your camper have an instrument they will be bringing to camp?*
- Yes
- No
If "Yes", which instrument?
- Acoustic Guitar
- Banjo
- Fiddle
The Birthplace of Country Music Museum's Summer Camp offers the opportunity to learn about several traditional string band instruments and then choose one to focus on for the week. Please use the dropdown menus to select the order of instruments that your camper is most interested in learning:
First Choice
Second Choice:
Second Choice:
Third choice:
Third choice:
Are parents married and living in the same household? If "Yes", then it is not necessary to fill out address information for secondary parent/guardian, however, phone numbers should be entered.*
- Yes
- No
Parent/Guardian #1 living with child*
Parent/Guardian/Child Address*
Street Address Address Line 2 City State ZIP Code
Email*
Primary phone*
Secondary phone*
Work phone
Parent/Guardian #2 name (if applicable)
Address (if living in a separate household)
Street Address Address Line 2 City State ZIP Code
Email
Primary phone
Secondary phone
Work phone
Does your child have any known allergies (including foods) or general dietary restrictions?*
- Yes
- No
If "Yes", please specify
Does your child require medication on an ongoing basis?*
- Yes
- No
If "Yes", please specify
If "Yes", is the medication self-administered or do you require camp staff member to administer the medication?
- Self-Administered
- Staff-Administered
Please include dosage, schedule of dosing, and storage instructions
For the safety of your child, it is important that we be made aware of any possible health issues he or she may be experiencing. In addition, please make us aware of any special needs or medical problems in the field below
Date of student's last tetanus shot*
Emergency Contact #1 (Besides Parents/Guardians)*
Name Relationship to child Primary phone State Secondary phone
Emergency Contact #2 (Besides Parents/Guardians)*
Name Relationship to child Primary phone State Secondary phone
Other Persons Approved to Drop Off & Pick Up Campers:
Please list the names and contact information of all persons other than Parents/Guardians who are allowed to pick up and drop off your child from Pick Along Summer Camp at the Birthplace of Country Music Museum. NOTE: Your child will not be released to anyone not listed here and designated individuals will be required to show photo ID. *Additional rows created by selecting the + symbol with mouse click.
Name: Primary Phone #: Secondary Phone #: Email Address:
Does the parent/guardian(s) authorize the Birthplace of Country Music to obtain immediate medical care and consents to the hospitalizations of, the performance of necessary diagnostic tests upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if any emergency occurs when parent/guardian(s) cannot be located immediately? It is also understood that his/her agreement covers only those situations which are true emergencies and only when parent/guardian(s) cannot be reached. Otherwise parent/guardian(s) can expect to be notified immediately.*
- Yes
- No
Name of Insurance Company
Policy Number
Other Arrangements
Child's Physician Contact Information
Name Phone number
Please check any of the following that can be administered to your child by our camp counselors:
- Tylenol
- Bactine
- Bee sting topical treatment
- Aspirin
- Benadryl
- Peroxide
- Ibuprofen
- Neosporin
- Ice or heat packs
I authorize the Birthplace of Country Music to capture, use, publish, and reproduce photographs, slides, moving pictures, or television video tapes of my child/ward for its records, public relations programs, social media, news coverage, and promotional purposes. Permission is granted for the camper to participate in all planned activities and programs, except as otherwise noted.*
- Yes
- No
I understand that payment is due in full at the time of registration to reserve a spot for my child. No refunds will be given to camp registrants if canceled less than two (2) weeks in advance. I also understand that no refunds or transfer funds will be made for withdrawal, failure to send, or incomplete attendance.*
- Yes
- No
In choosing "yes" below I state that I release and agree to hold harmless the Birthplace of Country Music, its agents, officers, employees and instructors, from any and all liability, claims, demands, or actions in any way related to injury and/or sickness which the child may suffer or incur as a result of program participication.*
- Yes
- No
Additional Comments:
The information contained in this form will remain valid for one year unless amended by a parent/guardian/child. For more information or assistance, please call 423-573-1927 or email education@birthplaceofcountrymusic.org.

Name:	Primary Phone #:	Secondary Phone #:	Email Address: