Xavier University Department of Art
Community Arts Program: Mardi Gras Indian Arts
Open to children ages 11-14
June 3-July 26, 2013
May 15, 2013
Dear Parent/Guardian:
The start of the Mardi Gras Indian Arts Summer Program is just around the corner!
Beginning on Monday, June 3th at 9 a.m. and continuing through Friday, July 26 students will
meet Monday through Friday 9 AM - 3 PM in The Art Village of Xavier University, located at
3520 Pine Street.
Please mail, or bring, the following completed documents for registration by
June 1 st :
• Please complete the 2013 application to participate in the Mardi Gras Indian Camp
Program (purple)
•
Camp Fee is $50 (Money Order Only) payable to Xavier University of Louisiana
with “2013 Indian Camp/Child’s Name” in the memo section
•
Copy of Birth Certificate (Child)
•
Copy of Social Security Card (Child)
•
Pre-Collegiate Summer Program Participant University Compliance Form (Please read
& complete the white forms, sign and return required copies of the requested
immunizations.) You must bring to University Health Services to complete this step,
504-520-7396.
•
Lunch is not provided
Feel free to call (504) 520-6723 if you have any questions. We look forward to your child’s
participation in our unique program.
Sincerely,
Bring completed application (color forms) to:
Xavier University Art Village, 3520 Pine Street, (Bordered by Edinburgh, Lowerline, Pine Street)
For more information call 504-520-6723
Xavier University Department of Art
Community Arts Program: Mardi Gras Indian Arts
Open to children ages 11-14
June 3-July 26, 2013
Trechere Washington
Art Village
Xavier University of Louisiana
Application
Parent/Guardian Name ______________________________________________________________________
Address ___________________________________________________________________________________
City/State/Zip ___________________
Contact: Home ________________ Cell/Work _________________ Cell/Work 2 _______________________
Emergency Contact (if we are unable to reach a parent)
Name ______________________________________
Phone __________________________________
Please indicate name, social security #, and date of birth for each participant.
Child Name (1) ___________________________________ SS#______________________ DOB _________________
Child Name (2) ___________________________________ SS#______________________ DOB _________________
Please answer the following questions about your participation in the art and cultural traditions of Mardi Gras: For
students:
o I attend Mardi Gras parades.
o I march/ride in Mardi Gras parades as a member of my school/church/other group
(please specify)_______________________________________.
o I create/wear a costume on Mardi Gras day.
o Please state any other forms of participation______________________________.
o I do not to participate in any Mardi Gras celebrations.
For parents:
o I am a Mardi Gras Indian Tribe member.
o I am a Mardi Gras Indian Krewe member.
o I am a Social Aid and Pleasure Club member.
o I am a Brass Band member.
o I attend Mardi Gras parades.
o I create/wear a costume on Mardi Gras day.
o Please state any other forms of participation_________________________________.
o I do not participate in any Mardi Gras celebrations.
Please check to confirm that you have completed the following required forms:
o Medical Concerns and Physical Limitations form:
o Media Release form:
o Designated Adult Pick-Up form
o Scholarship form
Enrollment Fee: $50 camp payment in Money Order Only, made payable to Xavier University. We Will Not Accept Bring completed application (color forms) to:
Xavier University Art Village, 3520 Pine Street, (Bordered by Edinburgh, Lowerline, Pine Street)
For more information call 504-520-6723
Xavier University Department of Art
Community Arts Program: Mardi Gras Indian Arts
Open to children ages 11-14
June 3-July 26, 2013
Personal Checks or Cash Note: Application will not be processed without all of the required forms. Summer Arts enrollment space is limited. Submitting an application does not guarantee acceptance into the program. Xavier reserves the right to cancel or alter the camp program should circumstances warrant. Students will spend up to 80% of their time developing hand-­‐sewing skills. Please consider your child’s needs and interests before enrolling her/him in the camp. Media Release
Xavier University will be documenting the progress of the project during the Mardi Gras Indian Arts
Program and will report its success to funders and sponsors. Documentation will also serve to
promote the work of its Community Arts Program and Department of Art.
I hereby grant Xavier University permission to record my child’s image, likeness and/or voice for use
on its website and by television, film, radio, printed media, publications, etc. I hereby release Xavier
University from any and all claims on its usage.
Parent/Guardian Name (PRINT)
Student’s Name
Parent/Guardian Signature
Date
Bring completed application (color forms) to:
Xavier University Art Village, 3520 Pine Street, (Bordered by Edinburgh, Lowerline, Pine Street)
For more information call 504-520-6723
Xavier University Department of Art
Community Arts Program: Mardi Gras Indian Arts
Open to children ages 11-14
June 3-July 26, 2013
Medical Concerns and Physical Limitations
YOU MUST BE CLEARED THROUGH XAVIER HEALTH SERVICES
PRIOR TO BEGINNING CAMP
Birth Certificate, SS Card are required for camp and Proof of Immunization is for the University
o My child does not have any medical concerns or physical limitations of which Xavier University
should be aware.
o My child does have medical concerns or physical limitations of which Xavier University should be
aware.
Please specify in the lines below the medical concerns (EX: Asthema, Allergies) or physical
limitations of your child. Please note: NO medications can be dispensed to your child during camp
hours.
__________________________________________________________________________________
____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Parent/Guardian Name (PRINT)
Student Name
Parent/Guardian Signature
Date
Bring completed application (color forms) to:
Xavier University Art Village, 3520 Pine Street, (Bordered by Edinburgh, Lowerline, Pine Street)
For more information call 504-520-6723
Xavier University Department of Art
Community Arts Program: Mardi Gras Indian Arts
Open to children ages 11-14
June 3-July 26, 2013
Scholarship Request
The Community Arts Program will provide a limited number of scholarships for students with the greatest
need. All financial information will be held in the strictest of confidence. For the scholarship request to be
reviewed, total household income must be verified.
Please attach:
1) A copy of your most recent tax return to this scholarship request form.
2) If you have not filed a tax return, please attach either a copy of your W2 form or a letter from your
employer on official company letterhead verifying your income.
Please list all other sources of income and the amounts as follows:
1) Public Assistance $________________________
2) Child Support
3) Alimony
$________________________
$________________________
4) Social Security
$________________________
5) Other(state name of income source) $________________________
How many persons in your household are dependent on this income?_______________________
Describe any special circumstances that you consider relevant (medical bills, recent change in family
circumstances, etc.). Use an additional sheet if you need more space.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Parent/Guardian Name (PRINT)
Student Name
Parent/Guardian Signature
Date
Bring completed application (color forms) to:
Xavier University Art Village, 3520 Pine Street, (Bordered by Edinburgh, Lowerline, Pine Street)
For more information call 504-520-6723
Xavier University Department of Art
Community Arts Program: Mardi Gras Indian Arts
Open to children ages 11-14
June 3-July 26, 2013
Designated Adult Pick-up Form
I understand that my child will only be released from Xavier University to adults designated on this form. The person
picking-up my child must show picture identification. If changes need to be made to this list, I am responsible for making
the updates to this form. I understand that no verbal changes will be accepted and all revisions must be made in writing.
The following individuals are designated to pick-up my child from the Xavier University Arts Program.
Adult
# 1 Name
Relationship to Child
Phone Number
Address
Adult
Relationship to Child
# 2 Name
Phone Number
Address
Adult
Relationship to Child
# 3 Name
Phone Number
Address
Adult
Relationship to Child
# 4 Name
Phone Number
Address
Parent/Guardian Name (PRINT)
Parent/Guardian Signature
_____________________________________________________________________________________________________________
Student Name (Print)
Student Signature
Last Revised ________________________
Bring completed application (color forms) to:
Xavier University Art Village, 3520 Pine Street, (Bordered by Edinburgh, Lowerline, Pine Street)
For more information call 504-520-6723
Xavier University Department of Art
Community Arts Program: Mardi Gras Indian Arts
Open to children ages 11-14
June 3-July 26, 2013
XUMIA Code of Conduct
Welcome to the Mardi Gras Indian Arts summer program at Xavier University of
Louisiana. The main mission of XUMIA is to support the purposes and goals of the
University by providing education, research and community service.
The XUMIA Code of Conduct is issued for the benefit of all participants of the summer
program. All participants are expected to respect the rights and property of others.
Conduct of individuals or groups that may disrupt or obstruct program-related work and
activities of the University community is prohibited in The Art Village Annex (TAVA).
Summer program participants are requested to familiarize themselves with the XUMIA
Code of Conduct. All members of the XUMIA staff enforce this Code.
•
Program participants expect a creative, learning environment. Talking that is
permitted must be done quietly. Disruptive behavior will not be tolerated.
(Remember other classes will be simultaneously conducted in one shared
space.)
•
Food and beverages are permitted in one designated space. Bringing any food or
beverage into the class area is prohibited.
•
Participants are not allowed in the computer area.
•
Only one student may use restrooms at a time after receiving permission.
•
Program participants should not engage in any behavior that interferes with the
normal activities of the Art Department.
•
Students are required to leave The Art Village Annex with supervision, at 3:00
PM and as requested during emergency situations or following the violation of
the XUMIA Code of Conduct.
Bring completed application (color forms) to:
Xavier University Art Village, 3520 Pine Street, (Bordered by Edinburgh, Lowerline, Pine Street)
For more information call 504-520-6723
Xavier University Department of Art
Community Arts Program: Mardi Gras Indian Arts
Open to children ages 11-14
June 3-July 26, 2013
Page 2 – Code of Conduct
Xavier expects all students to conduct themselves as mature and responsible citizens in
accordance with accepted standards of social behavior, to respect the rights of others
and to refrain from any conduct that obstructs the work of the university or injurious to
the welfare of the University.
In Summary:
•
Only show respect to all members of the program or any member of the Xavier
community.
•
Only eat or drink outside class in the designated area.
•
Only use the restroom with permission.
•
Only leave the building with supervision.
•
Only communicate using appropriate and respectful language.
I fully understand the rules and regulations listed in the XUMIA Code of Conduct. I
understand that failure to comply with any of the above policies at any level will result in
dismissal from the program without refund.
Student’s Signature ________________________________________ Date_______________
Parent’s Signature _________________________________________ Date_______________
Bring completed application (color forms) to:
Xavier University Art Village, 3520 Pine Street, (Bordered by Edinburgh, Lowerline, Pine Street)
For more information call 504-520-6723