the art room nyc, inc.

ART CAMP REGISTRATION FORM

camper name

First Name

Last Name

age

birth date

school and grade

week(s) or day(s) of camp desired (dates)

parent/guardian name

email address

phone (best)

(###)

###

####

home address

emergency contact - name

emergency contact - phone

(###)

###

####

physician's name

physician's phone

(###)

###

####

allergies and known medical conditions

list of medications

parent/guardian authorization and waiver: As the legal parent or guardian, I release and hold harmless the art room nyc, inc., its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of the art room nyc, inc. its owners and operators or in route to or from any of said premises, except for those arising from the art room's negligence.

signature of parent or guardian and date signed

regarding authorization and waiver

transportation: please list all who are authorized to pick up your child, and give us a contact phone number as well. We take the safety of your children very seriously.

signature of parent or guardian and date signed

regarding transportation authorization

permission for use of photos: I give permission to the art room nyc, inc. to use photos taken of my child making art with the art room AND/OR photos of my child’s artwork created at the art room to be used in marketing the art room's programs. (Your child’s first name, initial of last name, and age may be used in association with the image of him/herself and/or artwork.)

signature of parent or guardian and date signed

regarding permission to use photos

how did you hear about Summer Art Camp at the art room?

if Other, please tell us here: