Renaissance Bilingual Summer Camp 2017
Please tell me about your student artist
First Name: *
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Last Name: *
Your answer
Gender *
Age / Grade entering in Aug. 2017 *
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Parent's name *
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Parent's phone number and email address *
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Mailing Address: Street, City, State, Zip *
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Agreement To Participate & Liability Release
The student registered on this form has my permission to participate in Renaissance Bilingual Camp during indicated session(s). I agree that YancyArt.com, Yancy Villa-Calvo and/or artist's assistants will not be held responsible for accidents arising thereof. I am responsible for any medical obligations incurred during these camp activities and give the camp permission to seek treatment in case of injury or illness. I understand that I am ultimately responsible for my child’s behavior at camp and that he/she will be expected to behave and respect others. *
I agree to the above statement.
Media Release Agreement
By participating in the Renaissance Bilingual Camp, I grant permission to Yancy Villa-Calvo and/or YancyArt to use my daughter's and/or son's image and/or an image of any work he/she does as part of any event or class at YancyArt studio, whether the image is used for promotion of the studio or as part of any description of the art created at YancyArt. *
I agree to the above statement.
Please tell me about any health related issues, allergies, medication, dietary restrictions. If none, please indicate so. *
Your answer
Emergency Contact if parent cannot be reached. *
Name/ Relationship / Phone number (daytime or cell numbers).
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Please check all that apply. Amount includes all material, hot lunch and snacks. *
I will be happy to do siblings accommodations. Please call me (901) 283-1070 or email: yancyvilla@gmail.com
Required
Total Amount Due
Note: a $50 NON-REFUNDABLE deposit to hold your registration. It will be applied towards camp fee.
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Contact me at YancyVilla@gmail.com for any questions or accommodations.
Send your check to:
Yancy Villa-Calvo
8665 Roundtree Place, Memphis, TN 38016
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