Post on 30-Mar-2016
description
July 2 – September 3 2011
Fayette County Cultural Trust
Summer Art Camp 2011
Registration Please return this form to:
Fayette County Cultural Trust 502 South Pittsburgh Street Connellsville, PA 15425
724 626 0141 www.fayettetrust.org
Due to space and optimum instructor to student ratio the number of students registered in the Program
is limited to 12 participants per class.
Classes will be held 139 West Crawford Avenue Connellsville, PA 15425 724 320 6392
One form per student. Please Print.
Student’s Name:_________________________________________________________
Address:_______________________________________________________________
City:____________________________ State:_____ Zip:______________
E-mail address:__________________________________________________________
Daytime Telephone Number: ___________________________________
Alternate Telephone Number: ___________________________________
School attending:_____________________________________________
Grade:____________ Student’s age:_____________ Gender:__________
Parent or Guardian’s Name:_____________________________________
(___) Check here if information is same as above.
Address:______________________________________________________
City:____________________________ State:_____ Zip:______________
E-mail address:________________________________________________
Daytime Telephone Number: ___________________________________
Alternate Telephone Number: ___________________________________
Emergency Contact Name:_____________________________________
Emergency Contact Telephone:_________________________________
Fayette County Cultural Trust 2011 Summer Art Camp
Summer Art Camp Policies
Photographs
We periodically take photos of students working in class or with their finished products. These photos
may be used on our website (www.fayettetrust.org). If you do not want photos included on the
website, please let us know at the start of class. Only first names will be used with the photos.
Expected Behavior
All participants are expected to behave in an appropriate manner while in the class. We will work
with each child to make sure that he/she understands the rules and expectations. We reserve the
right to ask any child to stop attending classes if they have shown an unwillingness to follow the rules.
Child and Project Pick-up
We reserve the right charge an additional fee to keep your children past their class period. Please be
prompt! Finished projects will be kept for two weeks after you are given notice that they are ready
for pick up.
Hold Harmless Agreement
I hereby release, hold harmless, defend and indemnify Fayette County Cultural Trust, Summer Art
Camp, their affiliates, officers, members, agents, employees, and other participants from any and all
damages, injuries, claims and causes of action which may accrue to or be asserted by me or any minor
child of mine arising directly or indirectly out of my minor child’s participation in art classes/activities
at Summer Art Camp. I also give my permission to the aforementioned organization for the free use
of my likeness and that of my child or ward, in connection with any broadcast, telecast, print media or
other publicity. The undersigned hereby forever releases, discharges and covenants to hold harmless
Fayette County Cultural Trust and teachers from any and all claims, demands, damages, costs,
expenses, loss or services, actions and causes of action belonging to the undersigned or arising out of
any act or occurrence in connection with and particularly on account of all personal injury, disability,
property damage, loss or damages of any kind sustained or that may hereafter be sustained arising out
of the matters described herein.
Permission to Provide Emergency Medical Treatment
I authorize Michael Edwards to organize any required medical or first aid procedure, or to take the
undersigned student to the hospital emergency room for treatment. I understand that every effort
will be made to notify me or individual indicated as emergency contact beforehand by telephone.
This Release and Hold Harmless Agreement shall constitute a full and complete release of any
and all claims for all classes taken on or after the undersigned date.
PARTICIPANT NAME___________________________________________________________
PARENT SIGNATURE_______________________________________DATE _______________
Classes are held on Saturdays from
9:30 am-11:00 am for ages 6-9
11:30 am – 1:00 pm for ages 10-14
There is a $ 10.00 per session to participate.
Each week will feature a different art form.
Payment is due upon registration. Fees are non refundable.
July 2
July 9
July 16
July 23
July 30
August 6
August 13
August 20
August 27
Sept 3