registration form.

WHIMSICAL SCULPTURE PROJECT
APPLICATION
A free metal sculpture program for children ages 10-12
Please fill out form completely and return by June 29, 2015 to:
Kenan Center, 433 Locust St., Lockport, NY 14094, ATTN: Heather Bowen
Last Name
Gender
Male
First
Middle
Date
Age
Home Telephone
Female
Home Address
City
Other Telephone
State
ZIP
School
Grade
Full Name of Maternal Parent/Guardian
Best Contact Phone (circle one) home /work /cell
Full Name of Paternal Parent/Guardian
Best Contact Phone (circle one) home /work /cell
Parent Email Address
Emergency Contact
Phone #
Relationship
PLEASE SELECT THE WEEK OF YOUR CHILD’S PARTICIPATION: (1 week only)
Each session will take place in the Taylor Theater Meeting Room from 10:00 am – 12:00 pm.
 July 13, 15 & 17
 July 20, 22 & 24
WAIVER
I, the undersigned parent/guardian of _________________________________(child’s name), do hereby grant permission to
participate in any and all of the activities of the Kenan Center’s Whimsical Sculpture Project. I agree to be legally and
financially responsible, and agree to hold harmless the Kenan Center and its officers, agents and employees, from any and all
claims or actions arising against or in favor of my child or myself as a result of any act by, or event, occurrence, or accident,
happening to my child. I hereby give my permission for photographs and/or videos of my child to be used in promotional and
website materials in connection with this program and the Kenan Center.
Parent/Guardian Name (PRINT)
Signature
Date
ACCEPTANCE
There are a limited number of spaces available each week so parents are urged to apply as soon as possible.
You will receive notification prior to the start of the program confirming your child’s acceptance as well as
further details on schedules, classroom locations, and staff contacts.