July 2 – September 3 2011

Fayette County Cultural Trust

Summer Art Camp 2011

Registration Please return this form to:

Fayette County Cultural Trust 502 South Pittsburgh Street Connellsville, PA 15425

724 626 0141 www.fayettetrust.org

Due to space and optimum instructor to student ratio the number of students registered in the Program

is limited to 12 participants per class.

Classes will be held 139 West Crawford Avenue Connellsville, PA 15425 724 320 6392

One form per student. Please Print.

Student’s Name:_________________________________________________________

Address:_______________________________________________________________

City:____________________________ State:_____ Zip:______________

E-mail address:__________________________________________________________

Daytime Telephone Number: ___________________________________

Alternate Telephone Number: ___________________________________

School attending:_____________________________________________

Grade:____________ Student’s age:_____________ Gender:__________

Parent or Guardian’s Name:_____________________________________

(___) Check here if information is same as above.

Address:______________________________________________________

City:____________________________ State:_____ Zip:______________

E-mail address:________________________________________________

Daytime Telephone Number: ___________________________________

Alternate Telephone Number: ___________________________________

Emergency Contact Name:_____________________________________

Emergency Contact Telephone:_________________________________

Fayette County Cultural Trust 2011 Summer Art Camp

Summer Art Camp Policies

Photographs

We periodically take photos of students working in class or with their finished products. These photos

may be used on our website (www.fayettetrust.org). If you do not want photos included on the

website, please let us know at the start of class. Only first names will be used with the photos.

Expected Behavior

All participants are expected to behave in an appropriate manner while in the class. We will work

with each child to make sure that he/she understands the rules and expectations. We reserve the

right to ask any child to stop attending classes if they have shown an unwillingness to follow the rules.

Child and Project Pick-up

We reserve the right charge an additional fee to keep your children past their class period. Please be

prompt! Finished projects will be kept for two weeks after you are given notice that they are ready

for pick up.

Hold Harmless Agreement

I hereby release, hold harmless, defend and indemnify Fayette County Cultural Trust, Summer Art

Camp, their affiliates, officers, members, agents, employees, and other participants from any and all

damages, injuries, claims and causes of action which may accrue to or be asserted by me or any minor

child of mine arising directly or indirectly out of my minor child’s participation in art classes/activities

at Summer Art Camp. I also give my permission to the aforementioned organization for the free use

of my likeness and that of my child or ward, in connection with any broadcast, telecast, print media or

other publicity. The undersigned hereby forever releases, discharges and covenants to hold harmless

Fayette County Cultural Trust and teachers from any and all claims, demands, damages, costs,

expenses, loss or services, actions and causes of action belonging to the undersigned or arising out of

any act or occurrence in connection with and particularly on account of all personal injury, disability,

property damage, loss or damages of any kind sustained or that may hereafter be sustained arising out

of the matters described herein.

Permission to Provide Emergency Medical Treatment

I authorize Michael Edwards to organize any required medical or first aid procedure, or to take the

undersigned student to the hospital emergency room for treatment. I understand that every effort

will be made to notify me or individual indicated as emergency contact beforehand by telephone.

This Release and Hold Harmless Agreement shall constitute a full and complete release of any

and all claims for all classes taken on or after the undersigned date.

PARTICIPANT NAME___________________________________________________________

PARENT SIGNATURE_______________________________________DATE _______________

Classes are held on Saturdays from

9:30 am-11:00 am for ages 6-9

11:30 am – 1:00 pm for ages 10-14

There is a $ 10.00 per session to participate.

Each week will feature a different art form.

Payment is due upon registration. Fees are non refundable.

July 2

July 9

July 16

July 23

July 30

August 6

August 13

August 20

August 27

Sept 3