Registration Form Summer Art Camps 2019
Please fill out our registration form in it's entirety. Asterisk fields are required. Please give us as much information as you can so that we may help you child have the best experience at camp. At the end is our Parental Consent, Waiver and Release.
We're very happy to have you with us!
Child/Student
first name *
Your answer
last name *
Your answer
birthdate *
Your answer
Parent/Guardian 1
first name *
Your answer
last name *
Your answer
email address *
Your answer
home phone *
Your answer
work phone *
Your answer
cell phone *
Your answer
Parent/Guardian 2
first name
Your answer
last name
Your answer
email address
Your answer
home phone
Your answer
work phone
Your answer
cell phone
Your answer
Address
street *
Your answer
city *
Your answer
state *
Your answer
zip code *
Your answer
The following individuals are authorized to pick-up my child at the end of the day:
first name *
Your answer
last name *
Your answer
relationship *
Your answer
phone number *
Your answer
first name
Your answer
last name
Your answer
relationship
Your answer
phone number
Your answer
Winter Holiday Art Camp: Please check the box below.
President's Week Art Camp: Please check the box below.
Spring Art Camp: Please indicate the week(s) you would like to register for:
Summer Art Camp: Please indicate the week(s) you would like to register for:
*
Required
requested Drop-In Day date(s)
Your answer
Registration Fees
*
Before camp (8-9am)
Please note: we require 24 hrs notice to reserve before and aftercare.
*
After camp (3-5pm)
Please note: we require 24 hrs notice to reserve before camp and after camp.
*
If you would like to sign your child up for After camp, what time do you expect to pick your child up each day?
Your answer
In case of emergency, please contact
(Parent/Guardian(s) will always be contacted first. Please provide contacts other than the parent/guardian(s) listed above.)
first name *
Your answer
last name *
Your answer
relationship *
Your answer
phone number *
Your answer
first name
Your answer
phone number
Your answer
last name
Your answer
relationship
Your answer
Child's doctor
first name *
Your answer
last name *
Your answer
phone number *
Your answer
Allergies/Physical Limitations
Please let us know if your child has any allergies. We travel to the park or the Vivarium several times each week, a 20 minute walk each way, and expect that your child will be able to participate in this activity on his or her own, walking with our staff.
*
Your answer
Learning Difficulties/ Special Needs
Does your child have any special needs or disabilities that it would be helpful for us to know about? If so, please let us know how we can best meet the needs of your child. *
Your answer
Has your child had any educational counseling or testing that it would be helpful for us to know about? If so, please let us know how we can best meet the needs of your child. *
Your answer
Has your child had any change in family situation or an illness that it would be helpful for us to know about? If so, please let us know how we can best meet the needs of your child. *
Your answer
first name *
Your answer
Parental Consent, Waiver, and Release
Please read carefully, as this electronic signature is a binding agreement between you and Beth Hird/Dancing Paintbrush Studio. I hereby give permission for my child, _____________________, to participate in Dancing Paintbrush Studio Summer Art Camp, and I hereby execute the Agreement, Waiver, and Release, below, on his/her behalf.

1) I state that said minor is physically able to participate in said activity. If our staff finds that full disclosure of information about their camper has not been made, we reserve the right to contact the parent, inform the parent that the camper may not return to camp, and no tuition refund will be made.

2) I am aware that Dancing Paintbrush Studio teachers and staff will be driving my child to field trip locations using private vehicles.

3) In the event of an accident or illness, I understand that every reasonable effort will be made to contact the parent / guardian immediately. However, if I am not available, I authorize Dancing Paintbrush Studio teachers to secure emergency medical care as needed. Although I understand that Dancing Paintbrush Studio will make every reasonable effort to provide safe environment, I am fully aware of the special dangers and risks inherent in participating in the activity, which may include physical injury or other consequences arising or resulting from the activity. Being fully informed as to these risks, I hereby consent to the student participating in the activities mentioned above. I hereby agree to indemnify and hold Beth Hird, her staff, and entities mentioned above free and harmless from any loss, liability, damage, cost, or expense that they may incur as a result of the death or any injury or property damage that said minor may sustain while participating in said activity.

4) I give permission to photograph my child’s image, likeness, or depiction for use in advertisement in print and electronic media. I further waive any claim for compensation of any kind for use or publication of photographs.

I have carefully read this agreement, waiver, and release and fully understand its contents. I am aware that this is a release of liability and a contract between myself and Dancing Paintbrush Studio and I sign it of my free will.

last name *
Your answer
relationship *
Your answer
date *
Your answer
Did you remember to submit your payment through Paypal? *
Payment MUST be made in order to hold your space. Payment may be made here: http://dancingpaintbrushstudio.com/summer-art-camp/registration/
Required
Please tell us how you heard about Dancing Paintbrush Studio Summer Art Camp
*
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service