Campers Name *

First Name

Last Name

Camper Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number

(###)

###

####

Emergency Phone Contact

(###)

###

####

Parents/Guardians

First Name

Last Name

Parents/Guardians

First Name

Last Name

How did you find out about Rivertown Music&Arts Camp? Checkbox

Family/Friend

Local Business

Internet

Social Media

Teacher/School

e-Newsletter

Flyer/Ad

Rockland Parent Magazine

Current Student

Other

Were you referred by someone?

If yes, please let us know their name so we can thank them!

First Name

Last Name

SELECT A CAMP WEEK

Choose camp weeks. Curriculum is ongoing and unique each week.

All Four Weeks July 1ST - July 25th

Week 1: July 1 - July 5

Week 2: July 8 -July 11

Week 3 July 15 - July 18

Week 4 July 22 - July 25

PHOTO WAIVER

Occasionally. Rivertown Music prints and publishes promotional materials. Please select appropriately:

Yes, I grant Rivertown Music to use my photos and/or my child's photos.

No, I do not grant Rivertown Music to use my photos and/or my child's photos.