Page 1.
Registration Packet
“ ART, MUSIC, DANCE, THEATER, WRITING ”
FARMINGTON HARTFORD NEW BRITAIN PLAINVILLE
Your child is invited to attend the Multicultural Arts Saturday Program at
Central Connect State University.
There are six( 6) sessions open to students grade 2 – 4 from
Noah Wallace, Union and West District Schools, Farmington.
.
Program dates are: October 17, 24, 31, November 7, 14, 21, 8:45 am – 12:30 at the Central Connecticut State
University Fine Arts Building 1615 Stanley St., New Britain, CT 06050. The visual, performing arts and creative writing activities are taught by professional teachers, artists & performers in collaboration with the
CCSU Theater Arts Department. One session will include a field trip to the Mark Twain Museum, Hartford.
A concluding program for parents is planned for the last session 11: 30 – 12:30pm., November 21 at CCSU.
To enroll your child complete the attached registration packet and return it by October 20 to the program leader at your school:
Nicole Bastiaanse-Fritch, Molly Lantagne Suzanne Magnee
West District School Union School Noah Wallace School
114 West District Rd. 173 School Street 2 School Street
Unionville, CT 06085 Unionville, CT 06085 Farmington, CT 06032
860 673-2579 860 673-2575 860 677-1650
Email: bastiaansefritchn@fpsct.org lantagnem@fpsct.org magnees@fpsct.org
Students are enrolled as registration packets are received . Enrollment is limited to available space and funding provided by a grant from the Connecticut State Dept. of Education, Bureau of Choice
Programs
Completed forms must be submitted by October 9 in order for your son/daughter to participate the program.
Parents will be notified if their child is not accepted due to space limitations. These students will be placed on a waiting list
We look forward to your child’s participation in the Multicultural Arts Saturday Program. As research shows, participation in the arts can have a significant impact on a student’s creative thinking and academic performance. If after reviewing this information you need further clarification, please feel free to call the contact person for your district or:
Dr. Augustine Cofrancesco, Multicultural Arts Program Director,
Farmington Public Schools 860 965-9741, Email drco@inbox.com

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Parents must provide adult supervision at pick-up sites both before and after sessions.
Please note, on the registration form, if your child has any allergies or medical/health condition.
Attendance is encouraged at all six (6) sessions . Activities start promptly at 8:45 a.m., and end at 12:30.
In the event that your child is absent call 860 965-9741 or the program representative from your school district.
Student responsibilities:

Participate fully and responsibly in all 6 sessions

Adhere to all school regulations, which are in effect during the program as well as during transportation to and from program sites

Bring a creative/inquisitive spirit
In case of emergency call Dr. Cofrancesco, 860 965-9741.
Food will not be included in the Multicultural Program. Students should bring a healthy snack that does not contain peanut products. Drinks should be contained in plastic bottles or cans.
*Bus transportation:
Your child will be picked up at the school listed below and transported to and from CCSU. After the 12:30 dismissal, your child will be dropped off at the same location at the time listed below. Adult supervision will be provide on the bus as well as at the program site during each of the six sessions.
TOWN
Farmington
PLACE
West District School
PROMPT PICK UP
8:15 am
RETURN
12:55 pm
----------- Check if you wish to provide transportation for your child to and from the six (6) Saturday sessions at CCSU.

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(Return this portion of the registration packet)
CONTACT & HEALTH INFORMATION
Student Name: ___________________________________ D.O.B.: __________ Grade : _________
Street Address: ___________________________________________________________________
School Child Attends: ______________________________ Gender: ______ Race: ____________
Parent/Guardian: __________________________________ Phone:___________(W)____________
Email: ___________________________________________________________________________
Emergency Contact:_______________________________ Phone:____________(W)____________
If an accident or serious illness occurs, you will be contacted and your child will receive emergency treatment at a local hospital.
Does your child, have any limiting disabilities or identified as having special needs? Yes □ No □
_______________________________________ Special Ed. Classification:____________________
Please explain:_____________________________________________________________________
_________________________________________________________________________________
Is your child currently taking any medications (prescribed or otherwise, e.g. cold medicine)? Yes □ No □
Please List:_________________________________________________________________________
Milligrams per medication:____________________________________________________________
At what times during the day:__________________________________________________________
Do you have any allergies, reactions to medications or Dietary needs? Yes □ No □
If yes, identify and explain:____________________________________________________________
Are you allergic to bees? Yes □ No □
If yes, did you bring your epee-pen or your own medication? Yes □ No □
Note, We do not have a nurse on duty and therefore do not administer any medications.
Administration of all medications must be arranged by parents.
Immunization against measles
I certify that my child has received the required Immunization against measles .
Parent/Guardian signature:
_______________________________________________________
Date:
_________________________
* I am aware that neither this program nor Farmington, New Britain, and Plainville Public Schools provide health insurance coverage of any type for participants. I realize that any medical bills incurred will be my responsibility. My son/daughter has permission to be treated at the nearest hospital of my choice.

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TRANSPORTATION : Circle the location you wish your child to be picked up and dropped off.
TOWN PLACE PROMPT PICK-UP DROP-OFF
Farmington West District School
Noah Wallace School
8:10 am
8:20 am
12:55 pm
12:50 pm
_____ Check if you prefer to provide transportation for your child to and from the 6 sessions at CCSU.
List the name of a neighbor or relative who will assume temporary care of your child if you can’t be reached:
Name _______________________________________________Tel. No.__________________________
Address___________________________ ____________________________________________________
MULTICULTURAL ARTS SATURDAY PROGRAM RELEASE FROM LIABILITY FORM
Release made (date)________________2015 by _____________________________________________
Parent/Guardian
City of __________________________, State of, _Connecticut_________________
As a parent/guardian of __________________________________,of_____________________________
Name of child or ward City/State
________________________________________________________________________________________________________________
Specify child’s address if different
___________________________________(child/ward) has my permission to participate in the Multicultural
Arts Saturday Program including all field trips. I understand as part of the instructional program media technology is used to document student activities including performances for purposes of instruction, exhibitions or publications. I hereby release and discharge Farmington, New Britain, and Plainville, its agents, employees and officers, from all claims, demands, actions judgments and executions which the undersigned ever had, or now has, or may have against the Farmington, New Britain, and Plainville Public
Schools, its successors or arising out of, participation in the above named program.
I, the undersigned, have read this release and understand all its items. I execute it voluntarily with full knowledge of its significance.
Signature of Parent/Guardian :
___________________________________________________