2022 ROCK CAMP REGISTRATION FORM
         Camper Information                                                  Additional Info
         Last Name: ______________________________                           Do you own an instrument?____ Which ones? _______ 
                                                                             _____________________________________________
         First Name: ______________________________
                                                                             Do you have any experience with playing an 
         Grade Completed: ______                                             instrument?_____ Please describe_________________ 
         Birthdate:  ____ /_____ /_____   (MM/DD/YY)                         _____________________________________________
         Address: _________________________________                          Circle the instrument(s) that interest you:                           
                                                                             Guitar      Bass      Drums
         City: _______________   Zip Code:_____________
                                                                             Dominant hand:  Right    Lef
         Home Phone #:____________________________
                                                                             Would a guardian be willing to volunteer during camp? 
         Parent/Guardian Daytime Contact Information
                                                                             Shirt Size (circle):    YS / YM / YL / YXL 
         Guardian (1) Name: ________________________
                                                                                                               AS / AM / AL / AXL                   
         Day Time Phone #: ________________________
                                                                             Pricing
         Email Address: ____________________________
                                                                                                    Rock Camp
         Guardian (2) Name: ________________________
                                                                             5 Day Camp        May 23rd–27th, 2022    9am–12pm & 1pm-4pm
         Daytime Phone #: __________________________
                                                                             Camper(s):________ x $150 = _________________________
                                                                             ___Check enclosed     ___Cash/Credit paid at box office
         Alternate Emergency Contact Information
                                                                             Please make checks payable to: RiverPark Center
         Name: __________________________________                            101 Daviess Street, Owensboro, KY 42303
         Phone #:_________________________________                           Waiver
         Relation to Camper: ________________________                        I certify that all information given above is correct. I hereby 
         List the names of any adults/siblings who have your                 give permission to have staff arrange any emergency medical 
                                                                             care, including hospitalization if necessary. In all instances, 
         permission to sign your child out. (Any names not on                attempts will be made to contact the guardian first. The 
         this list will be unable to sign the camper out without a           participant is responsible for his/her medical coverage.
         handwritten note.)  
                                                                             I hereby release RiverPark Center and all teaching artists from
         ______________________________________________                      all claims arising from participation in any activity associated 
         ______________________________________________                      with this Day Camp.
         ___________________________________________                         I authorize the use of any photos taken during the camp for 
                                                                             future non-profit promotional purposes.
         Medical Information                                                 _________________________________       ____________
         Medical Issues (including allergies)? Y / N                                         (Guardian’s Signature)                              (Date)
         If yes, please explain: ______________________                      For more information, please contact:
         ________________________________________                            Matt Waller, mwaller@riverparkcenter.org
                                                                             Or call the box office: (270) 687-2770