The Art Studios

Day Camp Registration

Summer 2011

Date Registered: ___________________   Date of the camp:________________  Paid:_____________

CAMPER INFORMATION:

Camper Name: ____________________________________________________ Sex: ________________

Date of Birth: _____________________ Current Grade: ________

FAMILY INFORMATION:

Father:                                                                                         Mother:

Last Name: _____________________________         Last Name: ____________________________________

First Name: _____________________________        First Name: ____________________________________

Home Telephone #: (___)__________________         Home Telephone #: (___)_________________________

Bus. #: (___)____________________________         Bus. #: (____)___________________________________

Cell. #: (____)___________________________         Cell. #: (___)___________________________________

Email: _________________________________         Email: ________________________________________

MAILING ADDRESS OF FAMILY:      

Street: _________________________________

City: __________________________________

Postal Code: ____________________________

Alternate Contact (in case parents can not be reached)

Name:_________________________________________

Day Time Phone #:_______________________________

Alternate #:_____________________________________

Relationship to Camper:___________________________

Is there anyone other than those named above who is authorized to pick up your child?____________________

Name:_______________________________            Relationship to Camper:___________________________

HEALTH INOFRMATION:

Health Card #: ________________________________________________________

Family Doctor: ________________________ Telephone # : (___)_________________

Please check if camper has any of the following and detail below:

____ asthma ___epilepsy ____ diabetes ____allergies (food, drug, other)

Details: ______________________________________________________________

Does camper take any medications? Yes__________ No __________

Will camper be taking any medications while at camp? Yes_____ No __________

IF YES, Name of medication __________________ Dosage______________ Time________________

Any restrictions while at camp? __________________________________________

PARENT’S AUTHORIZATION:

I hereby give consent for my child to participate in The Art Studios camp program and all of its activities unless I advise you in writing. I give permission for The Art Studios to use any photograph my child is in for promotional material. To the best of my knowledge, my child is in good health and I will notify the camp if he/she is exposed to any infectious diseases. I further release and agree to indemnify and hold harmless for The Art Studios, its officers, servants or assigns from any liability concerning our child’s involvement in The Art Studios programs, and further agree that the use of all for The Art Studios facilities is made at the risk of the registrant. In case of surgical emergency, I hereby give permission to the physician selected by the camp director, to hospitalize, to secure proper treatment for and to order injection, anaesthesia, or surgery for my child, as named on this form. Every effort will be made to contact a parent/guardian in the case of emergency.

Signature:___________________________________________                       Date:__________________________________

DATES:

Please select which sessions/dates your child will be attending camp at The Art Studios:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DROP OFF & PICK-UP:

Campers are asked to arrive at The Art Studios 8:30 - 9:00 am, and are to be picked up at 4:30pm. For your convenience we are offering extended evening programming until 5:30pm if this fits into your family’s schedule more easily. For later pick up, please add $10/per hour. Please indicate which dates you will need extended hours at The Art Studios.

PAYMENT:

We can accept payment for our day camp programs in-store or over the phone. Please complete this registration form, e-mail it or bring it into The Art Studios.  We are able to accept cash, Debit, Visa and MasterCard and personal cheques.