Fayette County Cultural Trust/ArtWorks Connellsville

Summer Art Workshops 2013 Registration

Please return this form to:

ArtWorks Connellsville 139 West Crawford Avenue, Connellsville, PA 15425

724-320-6392 www.artworksconnellsville.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 at 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/ArtWorks

Connellsville

2013 Summer Art Workshops

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 websites (www.fayettetrust.org & www.artworksconnellsville.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 _______________