1.
Personal Data Form for Performing Arts Summer Camp 2009
Print and take a copy of this form with you to the Camp. Also leave a copy at
home with a friend or relative.
Personal Information (Please complete form with Blocked Capital Letters)
Full name
Nickname Grade Level
Home address
Home phone
Mobile or cellular phone
Home fax
Home e-mail address
Birthday (MM/DD/YYYY) Current Age
Parents / Guardians Information
Mother’s full name
Father’s full name
Guardian’s full name (If not child’s Parent)
Business Information
Company / Place of work
Business address
Department / Job title
Business phone
Business fax
Your preferred e-mail address
Web page address
Emergency and Medical Information
Since we will be providing basic medical care (only ice-packs and band aids), Parents need to provide
emergency contact information. Anything more serious than basic care, parents will be notified via the
emergency contact information provided or at your place of work. If we are unable to reach you, an
ambulance will be called. PLEASE LIST EMERGENCY CONTACT INFORMATION CAREFULLY.
In case of emergency, contact
Emergency contact’s address
Emergency contact’s phone
Doctor’s name
Doctor’s phone
Doctor’s address
Medical insurance carrier or Card Vitale No.
Blood type
Website: http://www.kofiwalker.com Email: kofiomar@caribserve.net Tel: +59 0690 22 92 59 Fax: 590 27 63 83
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2.
Personal Data Form for Performing Arts Summer Camp 2009
Personal Information (Please complete form with Blocked Capital Letters)
Known medical conditions
Known allergies
Current medications
Please list any other known medical
condition the student may have.
Field Trips #1 #2 #3 #4
1st Dates July 10th July 17th July 24th July 31st
2nd Date August 7th August 14th August 21st August 28th
This program may not be able to meet all educational special
needs, so please list any below so we can make that
determination. These will be kept COMPLETELY CONFIDENTIAL.
Special Needs These needs will only be discussed with my assistant(s) / helpers.
Discipline
To ensure that all students have the best experience possible this summer, the following
Discipline Action Plan for Fire, Earth, Wind and Water will be in effect for this Performing Arts
Summer Camp.
If a student is disruptive in class, the student can expect the
Disruptive in Class following consequences.
1st Verbal Warning
nd
2 Supervised Time Out
rd
3 Parent phone call
Continuous disruption Student will be removed from the FEWW Camp with no refund.
I am kindly asking that you discuss these consequences with your child at home. During the first
week of classes I will also be reviewing these consequences with the students. After reading
through this form, please fill out all the sections. If you have any questions, please do not hesitate
to contact me directly on 0690 22 92 59 or send me an email at kofiomar@caribserve.net
Please note that photos and videos will be taken of all students in this activity and will remain my
property for future use in Community Performing Arts Activities.
Website: http://www.kofiwalker.com Email: kofiomar@caribserve.net Tel: +59 0690 22 92 59 Fax: 590 27 63 83
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3.
Personal Data Form for Performing Arts Summer Camp 2009
Personal Information (Please complete form with Blocked Capital Letters)
Parents’ / Guardians’ Signature
I hereby give my son/daughter permission to participate in the FEWW Performing Arts
Summer Camp Program. I have read and understand all the rules and regulations mentioned
above.
Parents’ / Guardian’s Signature:
Date:
Activities: Students will participate in all activities listed below.
Dance Dance Technique and Movement including Afro-Caribbean Dance
Direction and instructions will be given mainly in English but
Speech and Drama
performance will be in French and in English!
Poetry Poetry writing and recital of students own works using the theme FEWW.
Focus will be placed on building confidence in the child, building an
Modeling / Posture
awareness of posture and how best to publicly present themselves.
The Broadway Musical Theatre will focus on our Creole Traditions of
Percussion n Chant
Percussion and Chant using the 5 Gallon Water Bottles.
Students will be introduced to costume designing for film or stage
Costume Designs
production. This will be demonstrated in their Fashion Presentation.
Face Painting Introduction to Face Painting using the theme FEWW
Art and Craft Painting, Drawing, Craft, Cartoon or the creation of 3D images.
Field Trips Lé Gallion, Butterfly Farm, Kali’s Beach, maybe the Fire Department TBC!
Tuition: Please indicate your choice by ticking √ A, B or C
June 29th – July 31st, 2009 (Please Calculate your fees in the far right column) . Fees Your Fee
Camp I Registration Fee € 15.00
A Full package 4 weeks € 200.00
B - Weekly € 90.00
C - Daily € 25.00
TOTAL 15 % discount is applicable to 2 or more siblings! € 215.00
e.g. √ [A] 4 Weeks = € 215.00
rd th
August 3 – August 28 , 2009 (Please Calculate your fees in the far right column) . Fees Your Fee
Camp II Registration Fee € 15.00
A Full package 4 weeks € 200.00
B - Weekly € 90.00
C - Daily € 25.00
TOTAL 15 % discount is applicable to 2 or more siblings!
Website: http://www.kofiwalker.com Email: kofiomar@caribserve.net Tel: +59 0690 22 92 59 Fax: 590 27 63 83
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4.
Personal Data Form for Performing Arts Summer Camp 2009
Please email this form to kofiomar@caribserve.net or fax it to 590 27 63 83 for the
attention of Mr. Kofi Walker.
You may also return the form to the School for the attention of Madam Brookson in an
envelope with payment addressed to my attention. Marked FEWW Performing Arts
Summer Camp.
Herve Williams 1
Concordia, St. Martin
Thanks in advance for your time and interest.
Website: http://www.kofiwalker.com Email: kofiomar@caribserve.net Tel: +59 0690 22 92 59 Fax: 590 27 63 83
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