A Wonderful & Creative Experience |
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Art in a Box Co.
Summer Registration
Form 2014
Workshop Name:
____________________________Week:____________________Total Fee:$ ______
Early Registration: Y / N
Sibling Discount: Y /N Deposit: Y / N
Name:_______________________________________________________________________________
Address:_____________________________________________________________________________
Date of Birth: ____________Age:____________ M / F
Grade:______ School:____________________
Sibling(s)_______________________________________
Contact Information
1.Parent/Guardian
Name: __________________________Home#_______________Cell#___________
2.Parent/Guardian
Name:___________________________Home#_______________Cell#___________
Emergency Contact(if different from
above)________________________________________________
Medical Information
Name of Doctor: ______________________
Location:________________________Tel#_________________________
Name of
Dentist:______________________Location:_________________________Tel#________________________
Allergies:________________________________________________________________________________________
Medication:______________________________________________________________________________________
Pick-Up Information:
If assigned pick-up person is different than parent, please
provide their information.
Also, please provide a note for
day(s) of pick-up.
Name:__________________________________
Relation:___________________ Contact #:_____________________
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I give my child,______________________,
permission to participate in the summer camp at Art in a Box Co. I agree to
comply with all program rules and hereby indemnify and hold harmless the staff,
management, and visiting specialist(s) from any and all liability for injuries
incurred at the camp or off-site locations affiliated with camp.
Parent Name:
print______________________Parentsignature__________________________Date:______
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