ACANSA Spring Break Arts Camps
Complete and submit the information below to enroll youth in FREE Spring Break Arts Camps!
Espanol: https://goo.gl/forms/o1XQEtW8haRnFDO92
Email address *
CAMPER’s Name *
Your answer
CAMPER's Birthdate *
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DD
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Current Age *
Your answer
PARENT(s)/GUARDIAN(s) Name(s) *
Your answer
Preferred Primary Email Address (if different from email address noted above):
Your answer
Physical Address of CAMPER: (street/apt/city/state/zip) *
Your answer
Address of PARENT(s)/GUARDIAN(s) if different from CAMPER’s address
Your answer
CAMPER’s Primary Contact Telephone Number: *
Your answer
Does Primary Contact Telephone Number allow texts for any daily camp updates? *
Required
Is CAMPER eligible for the National School Lunch Program (NSLP)? *
Camp Selection
Please rank from 1 to 4 which ACANSA Spring Break Camps your CAMPER would like to attend. To see all camp opportunities, click here: https://acansa.org/2019-spring-break-art-camps/
PLEASE NOTE that placement in one or more camps is not complete until 1) ACANSA responds to confirm CAMPER’s enrollment and camp selection, and 2) all subsequent WAIVERS & RELEASES are completed by CAMPER/ PARENT/ GUARDIAN and received by ACANSA.
ACANSA retains the right to cancel, update, change the times and dates, or otherwise reschedule any and all ACANSA Spring Break Arts Camps.
Please choose only one selection each for CAMPER's 1st Choice, 2nd Choice, 3rd Choice, 4th Choice
1st Choice
2nd Choice
3rd Choice
4th Choice
DANCE with Ballet Arkansas (BEGINNER/INTERMEDIATE)
DANCE with Ballet Arkansas (INTERMEDIATE/ADVANCED)
SCREEN PRINTING @ The Hub
HIP-HOP ACADEMY with Big Piph (AM)
HIP-HOP ACADEMY with Big Piph (PM)
DRUMMING Up Percussion with Zinse Agginie
Medical Information
Instructors and assistants are not allowed to administer medication to CAMPERs. All necessary medications must be administered by CAMPER’s PARENT or GUARDIAN prior to or following camp sessions. No drugs, medication or delivery methods (other than an EpiPen or generic equivalent declared on this form) are allowed at camp.
CAMPER’s Physician: *
Your answer
Address of Dr.'s Office or Clinic *
Your answer
Phone of Dr.'s Office or Clinic *
Your answer
Preferred Hospital in case of medical emergency *
Your answer
Name of Insurance Company *
Your answer
Insurance Policy Number *
Your answer
Insurance Group Number *
Your answer
Please note any special requirements or conditions instructors need to watch for, e.g. seizures, allergies, diabetes, nose bleeds, etc.
Your answer
If allergies are a concern, will the CAMPER bring an EpiPen (or generic equivalent) to ACANSA activities? *
Name of PARENT/GUARDIAN with legal custody to be contacted first in case of illness or injury: *
Your answer
Relationship to CAMPER *
Your answer
Phone Number *
Your answer
Email *
Your answer
Name of Second PARENT/GUARDIAN/Contact in case of illness or injury: *
Your answer
Relationship to CAMPER *
Your answer
Phone *
Your answer
Email *
Your answer
Third emergency contact in the event PARENT(s)/GUARDIAN(s) cannot be reached:
Your answer
Relationship to CAMPER
Your answer
Phone
Your answer
Email
Your answer
Does your child have an IEP or a 504 Plan?
What general guidelines will help to provide the most successful and enjoyable camp experience for the CAMPER?
Your answer
MEDICAL WAIVER
In the event medical care is warranted for student registered herein (CAMPER), I authorize camp staff to proceed with the following in any order perceived as necessary:
Contact PARENT or GUARDIAN
Contact other authorized persons
Contact the child’s physician
Call 911
Medical personnel will determine whether child needs immediate care.

If PARENT/GUARDIAN or other authorized person cannot be reached in an emergency, PARENT/GUARDIAN
grants permission for camp staff to authorize that CAMPER receives medical attention from a duly licensed or recognized physician or surgeon in case of emergency.

Any expenses for such medical events are incurred by the CAMPER's family.

I RELEASE ACANSA, camp leaders, campsites, their employees, and any affiliates, of any responsibility or liability in case of accident, illness or injury.

I hereby generally and forever release and discharge without limitation; indemnify, defend, protect, and hold harmless; and agree not to litigate against ACANSA and/or its respective partners, officers, employees and agents, from and against any and all manner of claims, causes of action, or liability which I may have now or at any time in the future against ACANSA, and/or its respective officers, employees and agents, including without limitation, any faculty or staff members assisting with the program, which may arise out of or relate to any injury (including, but not limited to death), loss, damage or harm of any kind which may result or may happen to me during the period while participating in the ACANSA Spring Break Arts Camp program and, while in transit to and from the camp sites, including any injury (including but not limited to death), loss, damage or harm.

CAMPERs will abide by any and all rules and regulations set forth by ACANSA and spring break arts camp sites. It is acknowledged and agreed that CAMPER’s intentional or inadvertent failure to abide by these rules may result in immediate removal from the ACANSA Spring Break Arts Camp(s) without notice.

CAMPER and PARENT/GUARDIAN assume all risks inherent in ACANSA activities.

CAMPER and/or PARENT/GUARDIAN will maintain all medical and health insurance, which CAMPER/PARENT/GUARDIAN deem necessary to cover all risks of any kind in regard to camp activities. CAMPER agrees not to take part in any activities that would represent a danger to CAMPER due to CAMPER’s health or physical condition, regardless of whether CAMPER/PARENT/GUARDIAN has or have disclosed such condition to any officer, agent, employee, or volunteer of ACANSA. CAMPER/PARENT/GUARDIAN agree that if CAMPER does undertake any such activities, CAMPER does so solely at CAMPER's own risk and peril.

For and in consideration of the agreement of ACANSA and its affiliates to permit me to voluntarily participate in ACANSA Spring Break Arts Camps, I HAVE CAREFULLY READ THIS RELEASE AND WAIVER OF LIABILITY AND FULLY UNDERSTAND ITS CONTENTS. I ACKNOWLEDGE AND AGREE THAT THIS RELEASE AND WAIVER OF LIABILITY SHALL BE BINDING UPON MY SURVIVORS, HEIRS, SUCCESSORS, AND ASSIGNS. I AM AWARE THAT THIS RELEASE AND WAIVER OF LIABILITY IS A NEGLIGENCE AND INDEMNIFICATION AGREEMENT, AND I SIGN IT OF MY OWN FREE WILL AS A VOLUNTARY CONDITION FOR PARTICIPATION IN THE ACANSA SPRING BREAK ARTS CAMPS.

This Release and Waiver of Liability may be in addition to and does not revoke or modify any other agreement or release which may be executed in connection with ACANSA or its affiliates in the Spring Break Arts Camps.

This Release and Waiver of Liability shall be construed and enforced in accordance with the laws of the State of Arkansas, without regard to its choice of law principles.

CAMPER Name *
Your answer
Medical Waiver Acknowledgement *
Required
Date *
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ACANSA BEHAVIOR & CODE OF CONDUCT
CAMPER and GUARDIAN understand that guidelines, rules and regulations may be presented with regard to CAMPER’s participation in the ACANSA Spring Break Arts Camp(s). Refusal to follow these guidelines, rules and regulations risks the chance of CAMPER’s dismissal from the program.

The following rules apply to all CAMPERs:
● CAMPERs will show respect and courtesy to other people at all times.
● CAMPERs will show respect for property inside and outside any structures related to Camps.
● CAMPERs will behave in a manner that does not endanger themselves or others.

CAMPER Name *
Your answer
Behavior & Code of Conduct Acknowledgement *
Required
PHOTOGRAPHY/VIDEO WAIVER
ACANSA includes photos and/or audio-visual representations of CAMPERs, teachers, and camp activities on promotional collateral, including but not limited to the ACANSA and camp affiliates’ website(s), emails, mailings, social media, television, print, and paid media.

ACANSA makes every reasonable effort to be sure that CAMPER(s)’s full name, address(es), and/or telephone numbers will not be included in promotional collateral.

If a CAMPER's photo/video/likeness is utilized for ACANSA's promotional purposes, no compensation will be provided to CAMPER or CAMPER's family or representative.

Choose one: *
Camper's Name to be utilized in photo/video/media: *
Your answer
Photography/Video Waiver Acknowledgement *
Required
THANK YOU!
ACANSA looks forward to providing Spring Break Arts Camps for your Camper! Someone will respond within the next 2 business days to confirm your registration.
A copy of your responses will be emailed to the address you provided.
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