Teens Take over the Museum
14 – 18 y/o

8/10/19

12:00 pm – 4:00 pm

Free with Registration

Spend a few hours on the Saturday before returning to school with a spoken word jam, creating ink pour portraits, and works on paper. Contribute to a large-scale community painting too! High schoolers will be inspired by the individuality and power of the image and history portrayed by New York artist Firelei Baez and led by Creative Arts Therapist Lulu Figueroa.

Student Name *
Your answer
Parent or Guardian Name(s) *
Your answer
Phone Number(s) *
Your answer
Email(s) *
Your answer
In case of emergency who should we contact and at what phone number(s) *
Your answer
Pick up and Drop off Contact Name(s) and Number(s) *
Your answer
When will your teen be picked up for the day? *
Light snacks will be provided, I understand that other bagged lunches and snacks are required to be brought if wanted *
The Mennello Museum of American Art, its agents, and employees do not administer oral or topical medications. Teens must be able to administer or take medication by themselves. The following information must be filled in by the caregivers to provide Museum Staff the background to provide appropriate care. Provide complete information so that the camp can be aware of your teen's needs. *
Is the teen covered by family medical/hospital insurance?
If yes, would you like to provide medical information in case of an emergency? Family Physician Name | Clinic Name | Physician/Clinic Phone | Address | Insurance Company | ID Number | Group Number
Your answer
Does the Teen have any known food, medical or other allergies? If yes, list *
Your answer
Send only medications that absolutely must be taken during day. Must be in original package or bottle and placed in a Ziploc bag labeled with the child’s name. Must have a prescription label with (1) camper’s name and (2) dosage clearly printed. Must not be expired Medication will not be accepted if they fail to adhere to these guidelines. Please list all medications taken routinely and the reason for taking the medication:
Your answer
Does teen carry and emergency pen or inhaler? *
I attest that all immunizations required for school are up to date for the teen *
Date of last tetanus shot (Tetanus is usually included in the shot for Diphtheria and Pertussis [Whooping Cough]) *
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