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Fine Art Camp 2012 Registration and Agreement Form Child’s Name: _____________________________________________________ Address: _______________________________ Apt. _____ City ________State ____Zip ______ Child’s date of Birth: ___________________________ Gender: M ____ F____ School Name: _____________________________________ Grade entering in September _______ Parent Name: Mr. Mrs. Ms._________________________________________________________ Home Phone ____________________________ Cell Phone ___________________ Parent Work Phone _____________________ E-mail_________________________________ Other Parent or Guardian:_________________________________________________ Home Phone ____________________________ Cell Phone ______________________ Work Phone _________________________ E-mail ___________________________________ Please check off Sessions and Fees you are enrolling and paying for: You will receive a discount for enrolling in more that one session* as listed below, and can schedule weeks to meet your schedule needs.** Session #1 - June 18 to June 28 ____________ Session #2 - July 2 to July 12 ____________ Session #3 - July 16 to July 26 __________ Session #4 – July 30th to August 9th ___________ *You can choose any combination of sessions. **ART CAMP IS MONDAYS THROUGH THURSDAYS ONLY FEES: One Session = $800_____Two Sessions = $1,500____ Three Sessions = $2,200____ Four Sessions = $2,900______ REGISTRATION FEE: $50 (per year) MATERIAL AND TRANSPORTATION FEE: $75 per two-week session. SIBLING DISCOUNT of 5% on tuition $_________ TUITION TOTAL including registration, and material fees = $_________________ REGISTERATION, AND PAYMENT OPTIONS 1. Mail pages 1 and 2 signed to our Registrar with your credit card information or check: Arts in Action VAP, Inc. C/o Adams, 4489 Broadway Apt 2A New York, NY 10040. 2. Scan forms, and credit card information & email to Abigail Adams:AIAVAPOFFICE@gmail.com, 3. Fax forms to: 347-614-2558. To pay by credit card over the phone call our registrar Abigail at 917-282-8569. Total amount due is payable by cash, credit card, Personal check, or money order. Please make checks payable to Arts in Action VAP, Inc. The following adults are authorized to pick up my child: Name: ______________________________ Relationship: _________________ Phone: ________________________Alternate Phone: _______________________ You have the responsibility to inform AIAVAP if someone is not legally permitted to pick up your child or if someone other than those listed above are picking up your child. Let us know in advance in writing. 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 may have below. 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 you must supply AIAVAP with an EPIPEN, and instructions on its use if your child requires this treatment.
Arts in Action Visual Art Program (AIAVAP) Parent/ Guardian Terms and Conditions for Workshops, Classes or Summer Art Camp. For participants in our workshops, classes, or Summer Art Camp from 9/1/11 to 8/30/12 I understand and agree: 1. That this payment is for workshops or classes conducted 6/1/11 to 6/1/13 and that I shall not be entitled to any deduction for my child’s absences or illnesses during the workshop or class, that in the event of my child’s withdrawal or suspension (see item #3 below) from the workshop, classes or summer camp have started, I shall not be entitled to any refund of unused tuition. 2. That the Program cannot issue refunds for workshops, classes or summer art camp not attended due to the scheduling of half or full day school closings, illness or your personal scheduling issues. Please refer to the AIAVAP calendar posted on our website at www.artsinactionvap.org. 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 not picked up by 5:30 PM or time agreed upon with program director and myself in writing, I agree to pay a lateness fee of $20 per every 10 minutes that pass after agreed pickup time according to program policy. 5. 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. 6. That if my child incurs a minor injury, AIAVAP staff has permission to address the cut, scrape, or minor injury as needed. 7. That you will provide all information regarding your child’s particular medical issues and needs, and if your child has allergies and an EPIPEN has been prescribed for his/her condition, you will be responsible to provide the EPIPEN and give AIAVAP Staff instructions on how to administer it to your child. 8. That AIAVAP reserves the right to modify the workshop, change instructors or site as necessary, or to cancel the class not meeting enrollment; 9. That during the workshop, my child may be photographed and/or videotaped by AIAVAP personnel or its authorized agents exclusively for internal and/or promotional use; 10. 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. 11. That some classes may involve trips outside the building supervised by staff of the AIAVAP program. I give AIAVAP permission to take my child on any such trips organized as part of the Program, including (but not limited to) neighborhood parks, galleries, artist studios, museums and other schools; 12. That in consideration of allowing my child to participate in the AIAVAP 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. 13. 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 workshop, class or summer art camp 24 hours in advance. 14. That these terms of agreement #1-14 will be applicable for September 13, 2011 – August 30/ 2012. Parent/Guardian Signature:_______________________________________Date:______________ Printed Name:_________________________________________________
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