Child 1 - Name *

First Name

Last Name

Child 1 - Workshop Dates *

September 30 • Fall Leaf Art • Grades K-2

October 7 • Fall Leaf Art • Grades 2-5

December 2 • Winter Printmaking • Grades K-2

December 9 • Winter Printmaking • Grades 2-5

Child 1 - Date of Birth *

MM

DD

YYYY

Child 1 - Date of last tetanus shot *

MM

DD

YYYY

Child 1 - Physician *

First Name

Last Name

Child 1 - Physician's Phone Number *

(###)

###

####

Child 2 - Name

First Name

Last Name

Child 2 - Workshop Dates

September 30 • Fall Leaf Art • Grades K-2

October 7 • Fall Leaf Art • Grades 2-5

December 2 • Winter Printmaking • Grades K-2

December 9 • Winter Printmaking • Grades 2-5

Child 2 - Date of Birth

MM

DD

YYYY

Child 2 - Date of last tetanus shot

MM

DD

YYYY

If the following information matches what was entered for Child 1 above, you may check this box and proceed to enter Parent/Guardian information.

The Physician, Physician Phone Number, Insurance Coverage, Group #, and Insurance Membership # is the same as for Child 1.

Primary Parent/Guardian *

First Name

Last Name

Primary Parent/Guardian Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Alternate Pick-Up Adult (ID required for release; must be 18+) *

Please list an adult that you will authorize to pick up your child(ren) in the event that you cannot come.

First Name

Last Name

Alternate Pick-Up Phone *

(###)

###

####

Policies & FAQs *

By checking this box, I hereby acknowledge that I have read and understand the After-School Artists Policies & FAQs, including Cancellation & Refund Policies.

Liability Waiver *

As Primary Parent/Guardian, you individually and on behalf of your child, release and agree to hold Anna Wetzel Artz harmless from any and all liability and hereby assume all risk and responsibility and waive any claim or cause of action of any nature whatsoever arising on behalf of your child while at After-School Artists or otherwise in the care of its staff. You further agree to indemnify and hold harmless Anna Wetzel Artz, its agents, employees or contractors, whether paid or volunteer, against any and all claims which may arise from any injury to said child while participating in this program.

By checking this box, I hereby acknowledge that I have read and understand the above policy and agree to comply with its provisions.

Medical Release

In the case of an emergency involving your child, you understand that every effort will be made to contact you. However, in the event that you cannot be reached to make arrangements for emergency medical attention at the time of illness or accident, you hereby authorize Anna Wetzel Artz to provide urgent care for your child. You further authorize and consent to all medical, surgical, diagnostic and hospital procedures as may be performed or prescribed by a physician for your child, when such treatment is deemed necessary or advisable by a physician to safeguard your child's health and it is not advisable to take the time to contact you in advance. You waive your right to informed consent for treatment.

By checking this box, I hereby acknowledge that I have read and understand the above policy and agree to comply with its provisions.