WORKSHOP REGISTRATION FORM
Child’s First Name: ___________________ Last Name: __________________________
Address:_____________________________Apt.:_____City:____State:____Zip:______
School Name:___________________________Grade___ Age:___Gender: M__ F____
Parent/Guardian:______________________________Home Phone:_________________ Cell:___________________Work:_________________EX#________
Parent/Guardian:_________________________HomePhone:______________________ Cell:_____________________________Work:_______________________EX#_______
Emergency Contact:________________________Relationship:____________Phone:_____________
WORKSHOP NAME:_________________________________________________________________
DATE/S & TIME: ____________________________________________
HOW MANY CHILDREN: __________
WORKSHOP FEE: $ ______________
REGISTRATION FEE $50 for new families not currently enrolled in our classes. Good for one year from date paid.
TOTAL FEE: $____________
NOTE: No child will be permitted in our workshops unless all forms are completely filled out, and signed by parent or Guardian and fee is paid in full.
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 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 you must supply AIAVAP with an EPIPEN, and instructions on its use if your child requires this treatment.
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 registration 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, or Personal check. NOTE: Check payment option for new families not presently enrolled in our after school program will be required to submit personal checks a minimum of two weeks prior to the workshop date.
Please make checks payable to Arts in Action VAP, Inc.
Arts in Action Visual Art Program (AIAVAP) Parent/ Guardian Terms and Conditions for Workshops, Classes or Summer Art Camp.
For participants in our workshops, lasses 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:______________________________________________________