Summer Destinations

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Round House Theatre

Grades K-3: Destinations: All-Time Favorites

Monday August 19 - August 23

9:00am - 4:00pm

Silver Spring Education Center
925 Wayne Ave, Silver Spring, MD 20910

Students will dive into some of our all-time favorite destinations including Superhero City and Insectopia.

Available Sections

Enrollment: $450.00

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Student's Information

Legal First Name:

Nickname or Preferred Name (if different):

Last Name:

Gender:

Pronouns (for ex. He/Him/His; She/Her/Hers; They/Them/Theirs):

Date of Birth:

Name of School: (if applicable)

Grade for 2023-2024 School Year:

Please select your Student's t-shirt size:

Parent/Guardian Information

Primary Parent/Guardian Relationship to Student:

Name

Address:

City:

Country

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Postal Code:

Primary Phone Number:

Primary Email for all class communication:

Second Parent/Guardian Information

Second Parent/Guardian Relationship to Student:

Name:

Second guardian's Phone Number:

Second guardian's email address:

Does the Second Guardian reside at the same address as the Primary Guardian?

Additional Emergency Contact Information

Emergency Contact Name:

Emergency Contact Phone:

Relationship to Student:

In addition, the following people are authorized to pick up my camper:

Please include full name(s) and phone number(s)

Medical Information

Round House Theatre is committed to complying with the Americans with Disabilities Act (ADA). If any auxiliary aids or services are needed in order to participate, notification must be received no later than 1 month prior to the start of the program. Please email Education@RoundHouseTheatre.org or call (301) 585-1225

Allergies:

Please list any allergies your camper has, and indicate if your camper will be bringing an Epi-Pen

Medication

We discourage the administration of medication to students during the camp day. If medication must be administered during the camp day by our staff OR if your student will be self-administering medicine, you must complete a medical authorization form, which must be signed by the prescriber. All prescriptions must be in a container with the pharmacist's label attached.

Please indicate if you will need to receive a Medication Authorization Form so your camper can take medication during the camp day. (including emergency medications, such as Epi-Pens and inhalers)

Please list any medications your student is currently taking or will be taking that we should be aware of in an emergency situation:

Other Information

In order to best serve each student, please list all physical, psychiatric, cognitive, medical, emotional, learning needs, behavioral challenges, other special needs, or anything else you would like us to know. This information is invaluable to providing a positive camp experience. Indicate any activities that have been discouraged or limited by participant's physician. Please help us serve your child by being specific:

Physician Information

Physician Name:

Physician Phone Number:

Please enter the state in which the camper resides.

Is this camper exempt from any immunizations? If yes, please list the exemptions

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ETHNICITY:

Round House Theatre is committed to anti-racism, and is collecting demographic data to help track our progress in our commitments. We would appreciate your response to these questions.

Is your camper Hispanic or Latino/Latina/Latinx?

RACE:

Round House Theatre is committed to anti-racism, and is collecting demographic data to help track our progress in our commitments. We would appreciate your response to these questions, though it is enitrely voluntary

Please indicate your student’s race
select all that apply

Asian

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MEDIA RELEASE:

I understand that by completing this form Round House Theatre has my permission to use the image of participant as named on this form in publicity about Round House Theatre. If I do not wish Round House to use image of participant for publicity, I understand I must contact Education@RoundHouseTheatre.org to make this request.

Yes I understand and accept the above Media Waiver.

MEDICAL WAIVER:

In the event of an emergency, I give my permission to Round House Theatre to secure and administer treatment, including hospitalization, for the participant as named on this form.

Round House cannot administer over-the-counter or prescription drugs to my child unless that medicine is sent in a properly labeled container provided by the pharmacy and accompanied by a medical authorization form.

Round House assumes no liability for injuries or damages arising from participation in any class or program. Due to the strenuous nature of some activities, the participant is encouraged to consult a physician concerning fitness to participate.

Yes I understand and accept the Medical Waiver.

REFUND POLICY:

I understand a full refund will be made when a program is cancelled due to insufficient enrollment. A full refund, minus a $25 processing fee is available if the participant is withdrawn at least 30 days prior to the start date of the program. A 50% refund is available if withdrawing less than one month but more than two weeks prior to a program's start date. No refunds will be made within two weeks of program's scheduled start date and/or after a program has begun.

Yes I agree.

ADDITIONAL POLICIES

Rules and guidelines are intended for the safety and protection of all children and staff. Please review our Participant Code of Conduct with your student (in our information pack). If negative behavior persists, RHT will consult with parent/guardian. If a student is unable to correct behavior which is dangerous or disruptive to the program, suspension or dismissal from the program may occur.

Yes I agree.

I understand that all Destinations and Playmakers campers are only released to those who are authorized for pick-up on the above form.

I understand that all Teen Institute campers are self-released for lunch and at the end of the camp day.

Summer Destinations

Grades K-3: Destinations: All-Time Favorites

Available Groups

Available Sections

Class Place $450.00

Class Place $450.00

Student's Information

Parent/Guardian Information

Second Parent/Guardian Information

Additional Emergency Contact Information

In addition, the following people are authorized to pick up my camper:

Medical Information

Allergies:

Medication

Other Information

Physician Information

*The Box Office is open Monday-Friday 11am-5pm.

Details

Summer Destinations

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Name

Grades K-3: Destinations: All-Time Favorites

Description

Purchase items

Available Groups

Available Sections

Quantity for Enrollment

Class Place $450.00

Quantity

Class Place $450.00

Additional items

Student's Information

Parent/Guardian Information

Second Parent/Guardian Information

Additional Emergency Contact Information

In addition, the following people are authorized to pick up my camper:

Medical Information

Allergies:

Medication

Other Information

Physician Information