Stardust Ceramics Summer Kids Camp 2012
Registration Form
(Please Print and fill out. Mail or bring in with payment)
Stardust Ceramics
214 S. 4th Street Unit 1
Perkasie, Pa 18944
(215) 257-2632
Kid Name(s): _________________________
Age(s): ________________________________
Address:________________________
Email:_________________________________
City:____________ State:__________ Zip Code:______
Phone Number:___________________
Parent and/or Emergency Contact Names Information
Name:____________
Day Time Phone:______________
Cell Phone:____________
Additional Information: (Allergies, Medical Conditions....) ________________________________
_______________________________
______________________________
** Register Before June 1st to guarantee enrollment
Peace, Love & Pottery June 25th - 29th
_____ Mornings 10A.M -12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday- All Week
Holiday Hoopla July 2nd - 6th (Closed July 4th)
____ Mornings 10A.M -12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday -All Week
Down By The Sea July 9th - 13th
_____ Mornings 10A.M -12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday-All Week
The Harry Potter Experience July 16th - 20th
_____ Mornings 10A.M -12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday- All Week
A Colorful Universe July 23rd - 27th
_____Mornings 10A.M-12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday- All Week
Critter Club July 30th - August 3rd
_____ Mornings 10A.M -12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday- All Week
Jungle Journey August 6th - 8th
_____ Mornings 10A.M -12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday- All Week
Fantasy Fairies & Friends August 13th - 17th
_____ Mornings 10A.M -12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday- All Week
Mickey & Friends ( Additional $20.00) August 20th - 24th
_____ Mornings 10A.M -12P.M $90.00
_____ Afternoons 1P.M-3:00P.M $90.00
_____ Full Day 10A.M-3P.M $180.00 (Please Bring Lunch)
(Circle the days that will be attending)
Monday - Tuesday - Wednesday- Thursday- Friday- All Week
Total of Weeks/Days_________________
Subtotal $_______________
I hereby authorize the staff of "Stardust Ceramics" to act for me according to their best judgment in any emergency situation requiring medical attention, and I hereby waive and release the store and its employees from any and all liability by the above artists participation in the programs outlined in the brochure. My signature on the waiver also states that the above artist is covered by my personal medical insurance plan.
signature__________________________________date_________
print name__________________
relationship to artist______________________
