Text Box: NORTHWEST AERIALS KIDDIE & SUMMER CAMP REGISTRATION FORM    NAME(S):  __________________________________________________________AGE(S):  ________    PHONE:  _________________________________ EMERGENCY #:  ____________________________    ADDRESS:  ___________________________________________________ CITY:  _______________   ZIP:  ______________ E-MAIL:  ________________________________________________________   ALLERGIES or MEDICAL CONCERNS WE SHOULD BE AWARE OF:  __________________________________________________________________________________ WHICH CAMPS ARE YOU REGISTERING FOR?    Week Mon Ext Care? Tues Ext Care? Wed Ext Care? Thurs Ext Care? Fri Ext Care? 6/23-6/27                     7/7-7/11                     7/14-7/18                     7/21-7/25                     7/25-8/1                     8/4-8/8                     8/11-8/15                     8/18-8/22 For Drama Camp See Drama Camp Flyer                  8/27-8/31                         Kiddie Camp Only?  Please indicate in the appropriate box above.   DO YOU NEED EXTENDED CARE :  Please indicate approximate pick up time in the boxes above for which you will need extended care. The following people are authorized to drop off and pick up my child:  _______________________________________________________________________________________   The following is my special code word for pick up:  _______________________________________________    TOTAL AMOUNT ENCLOSED:  _____________PAYABLE TO NWA. (FEES MUST ACCOMPANY THIS REGISTRATION FORM )    VISA/MC #: ____________________________________________________  EXP. DATE:  _________   SECURITY CODE:  ________ SIGNATURE:_________________________________________________ MEDICAL AUTHORIZATION AND RELEASE The  above student(s) has my approval to participate in the Summer Camp organized by Northwest Aerials, Inc.  I understand that like all physical activities, participation in gymnastics, dance, trampoline and swimming carries with it a reasonable degree of risk and agree that neither Northwest Aerials, Inc., nor its officers, directors, operators, agents or instructors may be held liable in any way for any occurance in connection with the student’s participation in the summer camp which may result in serious injury or other damages to me, my family, heirs or assigns.  In consideration of being allowed to participate in such programs, I further personally assume all risks in connection therewith, whether foreseen or unforeseen, and further to save and hold harmless said corporation, its officers, directors, operators, agents or instructors from any claim by me, my family, estate, heirs, or assigns arising out of such participation.   I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS.  I AM AWARE THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME AND NORTHWEST AERIALS, INC., AND I HAVE SIGNED THIS OF MY OWN FREE WILL.      I, as parent or guardian of _________________________________________________give my permission for him/her to participate in the Northwest Aerials Summer Camp and in consideration of his/her participation, agree individually and on behalf of him/her to the terms of the above agreement and release of liability.   Northwest Aerials, Inc. has my permission to secure emergency medical attention if I cannot be reached immediately. IN REGISTERING THE ABOVE STUDENT I UNDERSTAND THAT THERE ARE NO REFUNDS, CREDITS OR TRANSFERS ON CAMP PAYMENTS   Parent/Guardian Signature:  _____________________________________________  Date:  ________________ NO ENROLLMENT WILL BE ACCEPTED WITHOUT FULL PAYMENT