Art Camp Registration Form
9-10 Saddle River Rd, Fair Lawn, NJ 07410
CAMPER AND PRIMARY CONTACT INFORMATION
Camp Week(s) /date №№____________ Student Name: ________________________
Date of Birth: _____________ Age (at the time of the Camp): ______ Grade: _______
Name of Parent/Prim. Contact: ________________________________
Cell Phone_______________________ Facebook Contact____________________________________
Name of Parent/ Sec. Contact: _________________________________
Cell Phone_______________________ Facebook Contact_____________________________________
Home Address
____________________________________City: _________________________ State: _____ Zip Code:_______________
Home Phone: ______________________ Work Phone____________________
Email address____________________________________________________
EMERGENCY CONTACTS (please provide two additional people, different from the parent/guardian listed above, who would automatically be the first person we contact)
First Contact’s Name: ________________________________Relationship:
Home Phone: _________________ Work/Cell Phone: ____________________
Second Contact’s Name: ______________________________Relationship:
Home Phone: _________________ Work/Cell Phone: _____________________
Medical information:
Insurance # and provider name/phone number:____________________________
Medical Doctor name and Phone number:
Medication in use:
Vaccination list/ dates – Please add a copy of the current immunization record!
SAFETY INFORMATION (please list all known conditions so we can accommodate your camper’s needs)
Does your camper have any medical conditions, allergies, or special needs the staff should know about?
YES/ NO, specify if yes
Does your camper have any behavioral or emotional issues the staff should know about?
YES/ NO, specify if yes
Is your camper taking any medications to treat these conditions?
YES/ NO, specify if yes
Other information you think we should know ( please add a page if needed)
Need Afterhours? YES/ NO, If yes(7-9am or 3-6pm) please submit the afterhours form to [email protected]
Refund and Cancellation: For cancellations made prior to May 1, a refund minus $200 non-refundable deposit will be issued. For cancellation after May 1, the total fee is forfeited. In the event that your child enrolls in camp and withdraws because of homesickness there will be no refund, but we may offer a different session in case we have space free of charge.
Camper Dismissal: A camper whose behavior is disruptive to the camp program or harmful to himself/herself, others, or the property of camp or others, will be dismissed at the discretion of Camp Owners, with no refund of fee.
Testimonials. We, the undersigned parents (or guardians) of the camper named on this application, acknowledge that we are fully aware that certain elements of danger are inherent in the activities sponsored by Art Studio 5005, which are beyond the control of the agents, the land owners and employees of Art Studio 5005, and that participation in any program activities may entail unavoidable risk of personal injury, death, and loss of or damage to property. We are aware of the types of activities in which the child will be participating during his/her stay and have been given ample opportunity to ask any questions which we may have about the environment the child will live in and the activities that he or she will participate in. We are aware of the dangers that are inherent in the operation of any child’s camp and in the child’s participation in all camp activities on or off premises of said camp including, but not limited to, hiking, athletics, including bodily contact, playing in sprinklers, use of tools and equipment, backpacking, swimming, outdoor-living skills, and vehicular travel. We grant permission to use any photograph or video for promotional use, knowing it will be done in good taste.
We have read and understand the terms and conditions of this Agreement/Waiver and we agree to subscribe to them.
Parent/Guardian Name___________________________________ Date: ___________
(if only one signature, consent is implied from other parent)
I verify that all the information I have provided in this document is true to the best of my knowledge.
X_________________________________________Your signature/
print name:
WHEN TO SHOW UP AND WHAT TO BRING
Camp is Monday-Friday, 9:00-3:00, with a possible after-hours at All Bright Summer camp for an additional fee. Email us if you need aftercare, before the camp starts! Camp provides all the necessary instruments, equipment, and teachers , as well as a snack and a hot lunch. Campers may bring lunch boxes just in case, or if they have special meal needs. You should also have a change of comfortable summer wear, extra shorts, tees, clothing suitable for art and messy paints (an old tee is perfect!), sandals good for sprinkles, swimwear and a towel, sun block, hats as we will be outdoors every day. Please do not bring mp3 devices, players, notebooks, game-boys and other electronics…including the cell phones. If you need a child to have a cell phone- please submit it to us upon arrival! See you in our Camp!
Lena, Dasha, Borya
ArtStudio5005.com
914-772-6919 / 845-323-1960 [email protected]