After School Arts Registration Form - Spring 20 Sharon, Newburgh Student InformationStudents First Name*Nickname if PreferredStudent's Last Name*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*GirlBoyGrade in Spring 2020*1st2nd3rd4th5thSchool*Sharon ElementaryNewburgh ElementaryOtherIf 'other', please list what school your child attendsChurch Attended (if any)Transportation for your child from school will be (Please note we only provide transportation from Sharon & Newburgh Elementary)*Foundry Transportation from Sharon ElementaryFoundry Transportation from Newburgh ElementaryI will bring my childClass Options 4pm - 5pmFirst Choice*ActingArt FoundationsBallet/Tap Combo (Ballet & Tap Shoes Required)Clay (Additional $15 charge at first class)Second Choice (different than selected above)*ActingArt FoundationsBallet/Tap Combo (Ballet & Tap Shoes Required)Clay (Additional $15 charge at first class)Third Choice (different than selected above)*ActingArt FoundationsBallet/Tap Combo (Ballet & Tap Shoes Required)Clay (Additional $15 charge at first class)Class Options 5pm - 6pmFirst Choice*Clay (Additional $15 Charge at first class)Comic/Cartoon DrawingHip Hop DanceUkulele CircleSecond Choice (different than selected above)*Clay (Additional $15 Charge at first class)Comic/Cartoon DrawingHip Hop DanceUkelele CircleThird Choice (different than selected above)*Clay (Additional $15 Charge at first class)Comic/Cartoon DrawingHip Hop DanceUkelele CircleParent/Guardian InformationParent/Legal Guardian's Name* First Last Parent/Legal Guardian's Relationship to Child*Parent/Legal Guardian's Cell Phone*Parent/Legal Guardian's Home Phone*Additional Parent/Legal Guardian's Name First Last Additional Parent/Legal Guardian's Relationship to ChildAdditional Parent/Legal Guardian's Cell PhoneAdditional Parent/Legal Guardian's Home PhoneEmergency Contact (Other than the names listed above)* First Last Emergency Contact Phone*List all people, INCLUDING YOURSELF, approved to pick up your child*Child's Health InformationFood Allergy*YesNoIf yes, please list specific food allergiesAn allergy action plan is required for severe allergies requiring an epic-pen, medications, etc.List Any Other Medical Conditions (asthma, etc.) or Activity RestrictionsAre all child's shots current*YesNoIf no, please explainPaymentThe payment for Foundry After School Arts will consist of 4 monthly payments of $100 for the full 16 weeks. Should you elect to stop classes you must submit your request in writing to The Foundry Center for the Arts. You must submit your online registration by Friday, January 10, 2020 to secure your child’s spot. A separate registration form must be filled out for each student your are registering. A separate Transportation Form must be submitted to your child's school for permission to ride our bus transpiration from school to the Foundry.Child's Medical Consent(I) (We) the undersigned, parent(s)/guardian(s) of the registrant above, a minor, do hereby authorize the adult sponsors of the Foundry Center for the Arts, as agent(s) for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, which is deemed advisable by, and is required to be rendered under the general or special supervision of, any physician or at the hospital or other health care facility. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of the aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which may be determined by a physician or surgeon, as aforesaid, to be advisable in the exercise of his/her best judgement. By typing my name below, I am signing this agreement.Electronic Signature*Date* Date Format: MM slash DD slash YYYY Crowd Release NoticeThis notice serves to announce that filming, taping, and or photography will take place at the Foundry Center for the Arts during Foundry After School Arts. By entering our campus, you grant the Foundry Center for the Arts the right to photograph you and your dependent children, to record your voice and to use your likeness without compensation. You also agree to release the Foundry Center for the Arts from any liability in connection with the taping/video production in perpetuity. Video and still images produced from Foundry After School Art’s Activities may be used by The Foundry Center for the Arts in print publications (e.g. flyers, brochures) or video productions. Video and still images may be posted to the Foundry Center for the Arts website and social media accounts. By entering the Foundry Center for the Arts campus, you agree to allow your image to be used for these purposes.Electronic Signature*Date* Date Format: MM slash DD slash YYYY Almost Done...
