1. SUMMER FUN FOR GIRLS
2012 REGISTRATION FORM
INSTRUCTIONS: Please complete a separate registration form for each girl. Please be sure to read all
of the general camp information (including cancellation policies) before registering. If you pay by credit
card, you may fax your registration to (903) 258-9565 or you may scan it as a PDF and e-mail it to
melindac@tyler.net. If you are paying by check, please mail the check and the registration form to:
With Splash, LLC, Attention: Melinda Coker, PO Box 8423, Tyler, TX 75711.
Registration Information Medical & Health Information
Girl’s Name: ______________________________ Emergency Contact Besides Parent:
______________________________________
Street Address: ____________________________
Phone: ________________________________
City:________________________ State: _______
Cell: _______________ Work:______________
Zip: _______________
Girl’s Physician: _________________________
Grade Fall 2012:______ Date of Birth:__/__/_____
Phone: ________________________________
School Attending in Fall 2012: ________________
Any medical concerns preventing your child’s full
Parent(s)/Guardian(s) (with whom child resides) participation? If YES, please explain:
__________________________
_______________________________________
Home Phone: _____________________________
_______________________________________
Mom Work: _______________________________
Insurance Company: ______________________
Mom Cell: ________________________________
Insurance ID#____________________________
Dad Work: ________________________________
Dad Cell: _________________________________
Photo Release: Yes, Melinda Coker/With
Splash has my permission to use any photographs,
Parent e-mail for camp confirmation (required) art projects or videos of my child in any future
_________________________________________ promotion or advertising materials. I understand
my child’s name will not be used.
 Yes, I (we) the parent(s) or legal guardian(s) of above mentioned child, REQUEST, AGREE, and
GIVE APROVAL that in case an injury of the child occurs at the summer experience, and in the event that
I (we) or the physician indicated above cannot readily be reached or if time is too critical to attempt to
reach me (us) that the child be taken to an appropriate hospital at the discretion of Melinda Coker for
emergency care. I (we) further authorize the hospital and any attending physicians to perform any and all
diagnostic procedures and/or treatment required.
___________________________________________________________________/__/____________
Signature Date
Summer Fun for Girls 2012 Registration Form, Page 1
http://www.SummerFunForGirls.com

2. CHOOSE YOUR SESSIONS:
Girls may attend one session or all six. Pick as many as you would like. For example, even though a girl
attends both photography sessions, there will be different photo opportunities in each. The same will hold
true with the modeling and the healthy food sessions.
For each additional session (after the first one), you may take a $20 discount off the listed price. If two
girls from the same family sign up, the first girl will pay full price and the second one may take a $20
discount.
SESSION 1: JUNE 4-8, 2012, 10:00 AM - 1:00 PM (MONDAY - FRIDAY), $294.
A HEALTHY FOOD EXPERIENCE
SESSION 2: JUNE 11-15, 2012, 9:00 AM - 12:00 NOON (M - F), $279.
A PHOTOGRAPHY EXPERIENCE
SESSION 3: JUNE 18-22, 2012, 1:00 - 4:00 PM (M - F), $279.
A MODELING EXPERIENCE
SESSION 4: JULY 9-13, 2012, 9:00 AM - 12:00 NOON (M - F), $279.
A PHOTOGRAPHY EXPERIENCE
SESSION 5: JULY 16-20, 2012, 10:00 AM - 1:00 PM (M - F), $294.
 A HEALTHY FOOD EXPERIENCE
SESSION 6: JULY 23-27, 2012, 1:00 - 4:00 PM (M - F), $279.
 A MODELING EXPERIENCE
Girl’s Name: _________________________________Date _______/_______/_______
Parent Signature: ________________________________ Camp Total $____________
Payment Method: (Please circle one) Credit Card via Web Site Check Included
You may pay by check (made out to “with Splash, LLC”) or by credit card via the web site. Your credit
card statement will show a payment to “with Splash, LLC.”
If you pay by credit card, you may fax your registration to (903) 258-9565 or you may scan it as a PDF
and e-mail it to melindac@tyler.net.
If you are paying by check, please mail the check and the registration form in an envelope to:
With Splash, LLC, Attention: Melinda Coker, PO Box 8423, Tyler, TX 75711.
Summer Fun for Girls 2012 Registration Form, Page 2
http://www.SummerFunForGirls.com