filmcamp2014-registration

CONEXUS FILM CAMP 2014 Participant’s Name: Age: Participant Email: Hospitalization number: Allergies: Mailing Address (for mailing out the USB of Films) Street: City: Postal:

Parent / Guardian name(s): Home:

Cell:

Work:

Parent Email: ** For Office Use Only: full payment is required to register ** Staff: Please complete & date & initial when received.

Method of Payment: Cash: Cheque: # Payment Received *please check / circle* CONEXUSFILMCAMP w/ no USB of Films - $295.00 CONEXUSFILMCAMP w/ 1 USB of Films - $305.00 ANY OTHER NOTES:

*Cheques payable to: Saskatchewan Filmpool Cooperative or The Filmpool.

Please list specific areas of film or video making that interests you.

Where did you find out about this Summer Film Camp?

Please indicate: radio, Filmpool.ca, posters, website, word of mouth, facebook, twitter, ect.

Optional - Permission to leave unaccompanied: (Please read thoroughly.)

For the Parent’s and Guardians: It is our preference that participants arrive with a bagged lunch every day, with exception of Friday - when the participants are provided with a free pizza lunch! This helps to facilitate a smooth lunch break, with participants remaining on the premises and under the instructor’s supervision.

However – if permission is given by parent/guardian, participants may leave unaccompanied for lunch AND/OR at the end of the day.

SIGNING below, will give the participant permission to leave at lunch and after class unaccompanied by the Filmpool staff. The Filmpool and/or Conexus Credit Union or their affiliates will not be held accountable for the safety or any actions of the participant once they leave the premises.

If you DO NOT sign below, the participant will be kept on Filmpool premises, under instructor’s supervision until parent or guardian arrives to pick up the participant at the end of each camp day. Participant will also NOT be able to leave the premises for lunch.

Please CIRCLE the days in which you give permission for the participant to leave Filmpool premises UNACCOMPANIED: Circle the day(s) when participant is allowed to leave for LUNCH

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Circle the day(s) when participant is allowed to leave at DAY’S END

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Signing here is required if you are giving permission for registrant to leave the premises UNACCOMPANIED:

Signature: X

Printed Name:

MAIL, FAX or DROP OFF this FORM & PAYMENT to: The Saskatchewan Filmpool Cooperative #301-1822 Scarth Street, Regina, Sask. S4P 2G3 Phone 306.757.8818 Fax 306.757.3622

Would you give the Filmpool permission to use images from the camp for future promotional use?

This really helps us showcase what the participants do and shows the hands on elements of this camp.

Signing below indicates that you will give The Filmpool permission to use sounds and images recorded during this camp for future promotion of CONEXUS FILM CAMP. Thank you so much!

Parent/Guardian Signature: X

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