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Name of Child_____________________________ Date of Birth________________
Name of Parent/Guardian______________________________________________
Address________________________________ Email: ______________________
Telephone (home/cell/work) ____________________________________________
My child will attend: All Sessions _______
Monday Morning Session _______ Afternoon Session ________ Both_____
Tuesday Morning Session _______ Afternoon Session ________ Both_____
Wednesday Morning Session _______ Afternoon Session ________ Both_____
Thursday Morning Session _______ Afternoon Session ________ Both_____
Friday Morning Session _______ Afternoon Session ________ Both_____
*We will consider applications for morning only (9-12pm) or afternoon only(1-4pm) attendance, but preference will be given to full-day (9-4pm)participants.
Cost: $200 for the whole week, $50 per day, or $25 per session.
50% of total cost to be deposited with enrollment form, total paid by July 15 th 2015. Slidingscale and scholarship options available, please contact us!
Total Cost for my child: _______
Deposit Paid Now (50%): _______ Amount to be Paid by July 15th: ________

I hereby give permission for my child to participate in the summer 2015 Youth Arts Arise program.
I also agree that photos taken of my child during the program can be used for promotional purposes.
I further give permission, only if needed in case of medical emergency, to administer basic first aid and/or CPR and/or call 911 and/or transport to a hospital for medical treatment when I cannot be reached or if delay would be dangerous to the child's health.
Parent/Guardian Signature______________________ Date_______________
Parent/Guardian Name_________________________
Medical Insurance Information
Insurance Company: ______________________ Policy Number:_______________________
Policyholder Name:______________________________________
Does your child have any medical conditions, allergies, different learning needs, or any other special considerations that we should be aware of? _______________________________
Are you interested in carpooling? ____________