Opera Camp 2019 Registration Form

Child's Name*

Gender*

School Name*

School Grade in Fall 2020*

Date of Birth (MM/DD/YYYY)*

If so, who is his/her instructor?

Does the child sing in a choir?*

Church
School
Other
N/A

Parent/Guardian Full Name 1*

Parent/Guardian Full Name 2

Address*

City*

State*

Zip Code*

Email Address*

Alternate Email Address

Phone (Guardian 1)*

Phone (Guardian 2)

Which camp do you wish to attend?*

Create an Opera (grades 3-8): June 8-19
Art of Opera (grade 9-12): June 15-26
Sing! Move! Play! Session 1 (grades K-2): June 8-12
Sing! Move! Play! Session 2 (grades K-2): June 15-19

By electronic signature, I grant permission to Houston Grand Opera to photograph, film, or record my child for promotion of Summer Opera Camp and education activities within Houston Grand Opera and HGOco.*

Authorized Transportation 1 Name*

Relationship to child*

Authorized Transportation 2 Name

Relationship to child

Emergency Contact 1 Name*

Emergency Contact 1 Phone*

Emergency Contact 2 Name

Emergency Contact 2 Phone

Physician’s Name*

Name of Primary Policyholder*

Relationship to above-named child*

Insurance company*

Group number*

Policy number*

Preferred hospital*

Allergies*

Symptoms of allergen*

Steps to take in case of a reaction: *

*On the first day of Camp, please provide HGO staff with the necessary medication for administration in the event of an allergic reaction.

I grant permission to HGO staff to administer the following medication(s), or their generic equivalent, in accordance with the recommended dosage and intervals of administration in the event that I cannot be reached to administer this medication myself (Select all that apply)*

Tylenol (acetaminophen)
Advil (ibuprofen)
Aspirin
Pepto-Bismol
None of the above

*HGO cannot dispense, monitor, or maintain medication other than those indicated here for any child EXCEPT in the event of an allergic reaction for which we have receive an Allergy Action Plan and the necessary medication.

Does your child have any medical conditions we should know about, such as diabetes or sensory issues?*

Does your child’s school provide any accommodations that you would like us to know about?*

By electronic signature, I acknowledge that I am the parent or legal guardian of the above-named child, and I hereby release HGO, its staff, or representatives form any and all liability for any accident or injury which may occur during HGO activities.*

Would you like to apply for financial aid?

Yes
No
How many additional guests will attend?

Click submit below for instructions on completing the registration process.

Opera Camp Financial Assistance Eligibility Guidelines

Limited financial assistance is available and distributed in the order requests are received. Please use the chart below to determine if your family qualifies for a scholarship or discount. If you meet the criteria, fill out the fields below and click submit at the bottom of the page.

FAMILY SIZE *(includes everyone in household)*	INCOME
2	$30,044.00
3	$37,777.00
4	$45,510.00
5	$53,243.00
6	$60,976.00
7	$68,709.00
8	$76,442.00
9	$84,175.00
10	$91,908.00
11	$99,641.00
12	$107,374.00

You may still qualify for assistance even if you do not meet the above guidelines. For special circumstances please submit the following form and a page describing your current hardship

Parent/Guardian Name*

Primary wage earner’s occupation*

Annual yearly salary*

Parent/Guardian Name*

Secondary wage earner’s occupation*

Annual yearly salary*

Size of household*

Total yearly income*

Housing*

Own home
Rent (Apt or House)
Other

Monthly mortgage*

Monthly rent*

Please list normal monthly expenditures: (Include your average living expenses – i.e., food, clothing, etc.)*

Special circumstances (Optional)