APPLICATION June 1–12, 2015, 9 a.m. to 5 p.m. Daily Camp Contact: Karla Redding-Andrews, 478-742-5737 PLEASE PRINT First Name_____________________________ MI_____ Last Name __________________________________ Address____________________________________ City_____________ State_____ Zip______________ Camper Email______________________________________ Camper Cell ____________________________ Date of Birth _______________________________ Age____________________________________________ School Attending_____________________________________ Grade Entering Fall 2015_________________ Parent/Guardian Name_______________________________________________________________________ Parent/Guardian Address_____________________________________________________________________ Parent/Guardian Email Address _______________________________________________________________ Home Phone_______________ Work Phone______________ Cell Phone____________________________ Emergency contact/phone other than parent(s) ___________________________________________________ Health Insurance Information__________________________________________________________________ Allergies – please list__________________________________________________________________________ Dietary Needs – please list______________________________________________________________________ T-shirt size Women’s Tee_______ Men’s Tee_______ Do you play an instrument? Name instrument(s) ___________________________________________________ If yes, how long have you been playing? ___________________________________________________________ Are you bringing your own instrument? Y/N______ Please note the camp is not liable for personal instruments. This form MUST be signed by a Parent or Guardian. By signing below, I agree that my child will enroll in the Otis Music Camp for the full two weeks, June 1-12, 2015, and will fully participate in the curriculum. Tuition amount for both weeks: $225.00 Parent’s or Guardian’s Signature ___________________________________________Date________________________ Payment Method: Cash_______ Check_______ VISA _______MC_______AMEX____ Payment Date ___________ Credit Card Number___________________________ Expiration Date________ CCV________ Zip Code ____________ Please return completed application and payment by May 15 to the Otis Redding Foundation, 339 Cotton Avenue, Macon, GA 31201 or email to otismusiccamp@otisredding.com. There will be a $25.00 late fee for applications received after May 15. Please make checks payable to Otis Music Camp. All information is kept confidential.