SUMMER ARTS PROGRAM 2014

SUMMER ARTS PROGRAM 2014
Classes are held in the Museum’s galleries, outdoor courtyards, and Education Center. Advance
registration is required. Class sizes are limited. Registration is accepted by mail, fax or in person only.
Phone registration is not available. Enrollment can not be guaranteed until full payment is received.
All children must be signed in and out of the Education Center by a parent or guardian.
DAILY SCHEDULE
Drop off begins at 8:00 am
Morning Session: 8:30 am - 11:30 am
Lunch: 11:30 am - 12:30 pm
Afternoon Session: 12:30 pm - 3:30 pm
Pick at 3:30 pm
Aftercare: 3:30 pm - 5:00 pm
REGISTRATION FORM
Child’s Name_______________________________________________________________
Age__________________________
grade entering 8/14
Parent’s Full Name___________________________________________________________
Telephone (h) __________________(c) ____________________(w)___________________
E-mail_____________________________________________________________________
Address_______________________________________________City_________________
State_________Zip________Child’s Friend_______________________________________
The Museum welcomes children of all abilities. Making us aware of any special needs or
considerations is greatly appreciated and helps staff and art instructors ensure a successful camp
experience. Please list any known allergies/other conditions requiring special consideration:
__________________________________________________________________________
__________________________________________________________________________
In case of accident or serious illness, I request that I/we be contacted. I hereby give permission for
emergency medical treatment, which will include, but not be limited to, initial diagnostic x-rays and
other such procedures as the physician may deem necessary for the preservation of health. I agree
to assume all costs related to such treatment. I hereby waive and release Tucson Museum of Art
staff, teachers, and volunteers from and against all claims and medical and legal costs associated
from my child’s/children’s program participation.
Date__________Signature Parent/Guardian______________________________________
If the Museum must cancel a session, full refunds will be given. Otherwise all art camp costs are nonrefundable.
Don’t forget to dress for a mess or bring a smock.
One registration form per child.
140 North Main Ave. Tucson, AZ 85701 · 624-2333 · fax 624-7202
SUMMER ARTS PROGRAM 2014
Please check week(s) and session(s)
-6
9
ne
Ju
Price members/non-members
$100
/$155 Morning
$100
/$155 Afternoon
$200
/$310 Full day
1
3
1
ne
3
27
3-
2
ne
Ju
Ju
2
20
6-
-1
2
ne
l
Ju
Ju
4
5
8
-1
11
y7
4
y1
l
Ju
6
st
5
-2
1
y2
l
Ju
7
ly
Ju
u
ug
-A
1
28
8
$20 Aftercare
Total Class Fees
Membership (see below)
Please check here if you and/or your children do not wish to be
photographed for press and publicity.
GRAND TOTAL
MEMBERSHIP supports Tucson Museum of Art exhibitions and education programs. Visit the website at
Dual/Family
$50
Sustaining
$100
Patron
$250
President's Circle
$500
Director’s Circle
$1000
Membership:
New
Renewal
Check enclosed (Payable to Tucson Museum of Art)
Credit card:
MC
Visa
Am Ex
Disc
#________________________________________________________________
Exp. Date________________________ cvv code: ___________________
Cardholder’s Signature______________________________________________
140 North Main Ave. Tucson, AZ 85701 · 624-2333 · fax 624-7202
CDC/SGH# or name:____________________
Arizona Department of Health Services
Bureau of Child Care Licensing
Emergency, Information and Immunization Record Card
Child’s Name:
Updated:
Date Enrolled:
Home Address (#, Street, City, State, Zip Code):
Date Disenrolled:
Date of Birth:
Home Phone:
Sex:
Mother or Guardian Name:
Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional):
Contact Telephone Number:
Father or Guardian Name:
Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional):
Contact Telephone Number:
male
female
I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted:
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
If Medical care is necessary, call:
Contact Telephone Number:
Health Care Name:
Provider*
*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her
health and safety. It is understood by me that the expense of this service will be accepted by me.
In case of injury or sudden illness, I request that this individual be called first:
Does your child have insurance coverage?
No
Yes
Name of Insurance Company:
The following individual(s) may NOT remove my child from the facility:
Name(s):
Custody papers have been provided and are on file at the facility.
Telephone Authorization Code (optional):___
yes
_______
no
Immunization Information
(A licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and
Immunization Record card.)
For information regarding current immunization requirements go to:
www.azdhs.gov/phs/immun/index.htm or contact the Arizona Immunization Program Office at (602)364-3630.
One of these items must accompany the EIIR card at all times:
Copy of current official documented immunization record attached
Religious Beliefs exemption form signed by parent/guardian attached
Medical Exemption form signed by physician and parent/guardian attached
Signed Laboratory Proof of Immunity form attached
Notification of immunizations needed sent to Parent(s) or Guardian(s):
Updated immunizations received and attached:
mo /day/ yr
mo /day/ yr
mo /day /yr
mo /day/ yr
mo /day/ yr
mo /day /yr
Medical Information
No
Yes
Is child usually susceptible to infections and if so, what precautions need to be taken?
If yes, list precautions:
No
Yes
Is child subject to convulsions and what should be our procedure if one occurs?
If yes, specify procedure:
No
Yes
Is there any physical condition that we should be aware of and what precautions should
be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)?
If yes, list precautions:
No
Yes
Is child allergic to food or other substances?
If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs:
Additional comments:
Other special instructions:
This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by:
Parent/Guardian PRINTED Name:
SIGNED Name:
G:\Forms\Emergency Information and Immunization Record Card (9/11)
DATE: