VCU Department of Art Education
Creative Arts Day Camp
812 West Franklin Street
PO Box 843084
Richmond, VA 23284
804-828-7154
For additional information:
http://arts.vcu.edu/arteducation/community/creative-arts-day-camp/
Enrollment Form - Summer 2015
If enrolling a second child, please complete an additional enrollment form.
Child’s Name ________________________________________________________________
(Last)
(First)
(MI)
Mailing Address ______________________________________________________________
______________________________________________________________________________
Phone Number ______________________________________________________________
Rising Grade Level _____________ Age (as of date of enrollment)________________
Gender ____________ Allergies ________________________________________________
Enrolling Parent/Guardian Name _____________________________________________
(Last)
(First)
(MI)
Relationship to Child _________________________________________________________
Mailing Address (if different from child)________________________________________
_____________________________________________________________________________
Phone number _______________________________________________________________
(Home)
(Cell)
Email Address ________________________________________________________________
The following people have permission to pick up my child:
Name ______________________ Relationship __________ Phone Number___________
Name ______________________ Relationship __________ Phone Number __________
Name ______________________ Relationship __________ Phone Number __________
In the event that you cannot be reached, please list at least one emergency
contact:
Name ______________________ Relationship __________ Phone Number __________
Enrollment Choices
Please check all that apply.
Full day enrollment is Monday – Friday, 9am-4pm.
Morning block enrollment is Monday – Friday, 9am-12pm.
Afternoon block enrollment is Monday – Friday, 1pm-4pm.
___ I am enrolling my child in Session 1 (July 13 – July 17 / 5 days)
___ Full day enrollment ($200)
___ Morning block only ($110)
___ Afternoon block only ($110)
___ I am enrolling my child in Session 2 (July 20 – July 24 / 5 days)
___ Full day enrollment ($200)
___ Morning block only ($110)
___ Afternoon block only ($110)
___ I am enrolling my child in Session 3 (July 27 – July 31 / 5 days)
___ Full day enrollment ($200)
___ Morning block only ($110)
___ Afternoon block only ($110)
I qualify for a 5% discount off my total bill because I am:
___ VCU employee or student (for children or legal dependants of
VCU employees or students only)
___ enrolling more than one child at Creative Arts Day Camp
___ enrolling my child in multiple camp sessions
___ Early Bird Registration: We must receive FULL payment by April 1st
Total Registration Amount = __________________
Payment Information
**Full payment must be submitted with Enrollment form
to guarantee enrollment**
Please make your check payable to Virginia Commonwealth University.
Mail the enrollment form, photo and medical release form, and payment to:
Creative Arts Day Camp
Art Education Department
Virginia Commonwealth University
PO Box 843084
Richmond, VA 23284
Confirmation for enrollment and payment receipt will be sent by email.
Early Bird Registration forms and payment must be received by April 1st for the
discount to apply.
Regular enrollment forms and payment must be received by Wednesday, July
7th.
PHOTO RELEASE
I hereby authorize Virginia Commonwealth University to use photographs of my
child and his/her artwork for online photos that will be sent to each parent’s
email address, future advertisements for VCU Creative Arts Day Camp, VCU’s
student-teachers’ professional portfolios and/or on VCU’s website. I understand
that VCU shall NOT distribute these photographs to external media such as
television, newspaper, or magazine outlets without prior consent from the
registering parent or guardian. I certify that I have read the foregoing and fully
understand the meaning and effect thereof, and by my signature, have given
consent for such use.
Signature of Parent/Guardian_______________________________ Date:____________
MEDICAL RELEASE
Does the camper have any allergies to food, medication, insect bites, plants, or
anything else about which we should be informed? Yes______ No______
If yes, please describe in detail below: (Does the camper have an inhaler or epi
pen? ________________________________________________________________________
______________________________________________________________________________
I give permission for, ________________________ (Camper’s Name), to receive
emergency medical care deemed necessary while at VCU Creative Arts Day
Camp.
I do hereby release instructors and employees of Virginia Commonwealth
University from any responsibility or liability for any injury or illness which my child
may sustain while attending VCU Creative Arts Day Camp.
Signature of Parent/Guardian_______________________________ Date:____________
VCU Creative Arts Day Camp is a community program through the Department
of Art Education.
Department of Art Education
___________________________________________________________________________________________________
http://arts.vcu.edu/arteducation