Youth Theatre Camp with an Environmental Twist with Max von Duerckheim


June 18-29, 2012
10 a.m. -2 p.m.(10-15 year old) 
Performance on June 29, 4 p.m. and 6 p.m.
 Registration Fee - $25

Interested 10 to 15 year old wanting to learn about theatre, to make a difference in our environment, try healthy snacks, and perform for family and friends!

Registration Form

Student Name ____________________________________________________________

Age ____________________________________________________________________

Parent/Guardian Names _____________________________________________________________

Address _______________________________________________________________

Town, State, Zip ________________________________________________________

School Name ______________________________________________________

E-mail address for parent and/or student ________________________________________

Grade Level in School for 2011/12 ______________________________________

Phone Number___________________________________________________________

Emergency Contact Phone (cell # if available) ________________________________

Emergency Contact Name _________________________________________________

Student’s Pertinent Allergies (i.e. food, bees, etc)________________________________

Medication that will be brought to camp _______________________________________

(Refrigeration needed for medication? __________

I (student) ___________________________ am committed to attend all ten days of theatre camp June 18-29.
On the tenth day, I (parent/guardian) _______________________ will attend one of the theater productions on June 29.  We understand parents/guardians will be given two free tickets for the performances.    We grant permission for photographs and video to be taken of students(photos used for publicity of this event).

Signature Student ________________________________________________________

Signature Parent/Guardian __________________________________________________

Applications due June 1, 2012 with enclosed $25 check non-refundable registration fee (make checks to Quiet Creek Herb Farm). The cost of the workshop includes two tickets to the final performance.

Send application and check payable to Quiet Creek,  93 Quiet Creek Lane, Brookville, PA 15825

Questions?  Call Claire at 849-9662 or e-mail at quietcreek@windstream.net