Child’s First Name:_________________Last Name:_____________________Age/Birth Date:______________

Address:____________________________________Apt.:_____City:_________State:____Zip:____________

School Name:_________________________________Room #_________Grade:__________Gender:     M     F

 Please enter 1^st and 2^nd Choice of Class Day:

Monday _________Tuesday______Wednesday________ Thursday__________Friday___________

Parent/Guardian:__________________________Home Phone:______________Email:____________________

Cell phone: ______________________________Work Phone:_______________________________________

Parent/Guardian:__________________________Home Phone:_______________Email:___________________

Cell phone:______________________________Work Phone:________________________________________

Adult attending class:_______________________________Relationship:______________Phone:___________

NOTE: We require an adult accompany each child who attends our Artsy Toddler classes.

Medical Information:

Does your child have any allergies? Check: Yes_____No_____ On medications? Check Yes______No_____

If yes, please explain_________________________________________________________________________

Doctor’ s name:______________________________________________Phone:_________________________

PLEASE NOTE: Describe any medical or learning issues your child has on the back of this from. This information helps us accommodate your child's specific needs. You will be responsible for notifying us if your child has food or environmental allergies, and must supplying AIAVAP with an EPIPEN, and instructions on its use if your child requires this treatment.

Total due is payable by personal check, cash, money order or by credit card.

Make checks payable to Arts in Action VAP, Inc.

Send pages 1 and 2 signed to:

Arts in Action VAP, Inc., C/o Schmidt, 711 Amsterdam Avenue, #10G, New York, NY 10025

Arts in Action Visual Art Program (AIAVAP) Terms and Conditions

For participants in the Artsy Toddler Program

1.      That this payment is for the Fall2010 term and that I shall not be entitled to any deduction for my child’s absences or illnesses during the term; that in the event of my child’s withdrawal or suspension (see item #3 below) from the Program after classes have started, I shall not be entitled to any refund of unused tuition;

2.      That the Program cannot issue refunds for Artsy Toddler classes not attended. Please refer to the AIAVAP calendar posted on our website at www.artsinactionvap.org.  Please refer to AIA VAP’s class schedule if you are not sure if there will be class.

3.      That the Program requires my child to meet certain standards of behavior and that if my child fails to behave or demonstrates repeated unsatisfactory conduct, the Program has the right to dismiss my child from the Program;

4.      That if my child is injured and requires medical attention and I cannot be reached for instructions, I do hereby give authority to AIAVAP to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. I give permission for AIAVAP personnel to treat minor injuries on site.

5.      That AIAVAP reserves the right to modify the classes, change instructors or site as necessary, or to cancel the class not meeting enrollment;

6.      That during the Artsy Toddler class, my child may be photographed and/or videotaped by AIAVAP personnel or its authorized agents exclusively for internal and/or promotional use;

7.      That my child’s artwork produced during the AIAVAP classes, may be photocopied or copied using other methods to be used in publications and/or fundraising for AIAVAP without remuneration.

8.      That in consideration of allowing my child to participate in the AIAVAP Artsy Toddler program, I hereby release and forever discharge AIAVAP and Little Shop of Crafts and its officers, volunteers, employees, contractors and agents from any liability arising out of or based upon any bodily injury or property damage which may be sustained by my child while participating in such program.

9.      That each parent/guardian must notify AIAVAP by phone (212) 864-4883, (917) 343-4242 or email artsinactionvap@aol.com when their child will not be attending class 24 hours in advance.

10. That these terms of agreement #1-9 will be applicable for school year September 13, 2010 – June 17, 2011.

Parent/Guardian Signature:_________________________________________Date:______________________

Printed Name:_______________________________________________________________

ARTS IN ACTION VAP, INC. FALL Semester 2010

 PLEASE KEEP THIS PAGE FOR REFERENCE

 General Information:

 Arts In Action Visual Art Program, Inc.™ (AIAVAP) is a non-profit 501c3 organization that provides a unique, sequentially-structured art education program using a visual language that all fine artists learn to communicate through. Since 1987, Angela Tripi-Weiss, Director of AIAVAP, has spearheaded non-profit art programs that empower children. Ms. Tripi-Weiss, three-time Blackboard Award winner, has been called "one of the best visual educators in Manhattan...a tour de force" and directed Arts in Action at P.S. 87 in Manhattan for 18 years.

 FALL 2010 term: Mon., Sept. 13, 2010 – Friday, Jan. 31, 2011

Arts in Action Visual Art Program, Inc. is a not-for-profit corporation (Fed. ID 56-2322737)

Classes are held at Little Shop of Crafts, 94^th and Amsterdam Avenue, northeast corner

Arts in Action VAP, Inc. main phone: (212) 864-4883 or 917-363-4242 or artsinactionvap@aol.com

On-site phone at Little Shop of Crafts (for emergencies only): (212) 531-2723

Fees for Sept. 13, 2010 – June 17, 2011 $35 per regular Artsy Toddler class

Sibling discount (Sibling of a registered student will receive 5% off):

Please use separate forms for each child, and take the discount on the sibling’s form. Deduct $17.50 per sibling.

OTHER FEES: Registration fee: $25     ·    Materials fee: $25    

Payment plan – 2 equal payments, paid by post-dated checks only at registration. $20

Returned check fee: $25

Arts in Action VAP, Inc. reserves the right to cancel any classes due to under enrollment. Full refunds will be given and notice given before classes start on Sept. 13, 2010 if the class is cancelled.

Contribute to Arts in Action VAP Scholarship Fund! Help make Artsy Toddler accessible to all children who want to participate by making a donation to Arts in Action VAP. You can make your tax-deductible donation when you enroll your child at registration. Phone: (212) 864-4883 · fax: (212) 864-9166 · Email: artsinactionvap@aol.com · www.artsinactionvap.org