Participant Information Participant Name * First Name Last Name Participant Date of Birth * MM DD YYYY Age * Session * Options April Vacation Programming 4/18 - 4/21 Saturday Studios (Saturdays 10:30 - 12:30) - $20.00 Summer Session 1: July 15 - 19 (Monday - Friday, 9a-5p), $330 Summer Session 2: July 22 - 26 (Monday - Friday, 9a-5p), $330 Summer Session 3: July 29-Aug 2 (Monday - Friday, 9a-5p), $330 Summer Session 4: August 5-9 Monday - Friday, 9a-5p), $330 Summer Session 5: August 12 - 16 (Monday - Friday, 9a-5p), $330 Summer Session 6: August 19 - 23 (Monday - Friday, 9a-5p), $330 Summer Session 7: August 26 - 30 (Monday - Friday, 9a-5p), $330 PARENT/GUARDIAN CONTACT INFORMATION Parent or Guardian Name * First Name Last Name Parent or Guardian Phone * (###) ### #### Parent or Guardian Email * Address (Street or PO Box) * Address (City) * Address (State) * Zip Code * EMERGENCY CONTACT Emergency Contact (Someone other than parent or guardian) * First Name Last Name Emergency Contact Phone * (###) ### #### Relationship to Participant * HEALTH INFORMATION Participant's Physician's Name * First Name Last Name Physician's Phone * (###) ### #### Medical Insurance Provider/Policy Number * Does Participant have any health concerns Dot Art should be aware of? * Yes No If yes, please provide more information PERMISSION I give my permission for dot art to reproduce/distribute/broadcast photographs, video, or audio recordings of myself and/or my children or our artworks to further the goals of Dot Art in any way that the staff sees fit. In the event of injury or illness to myself or my son/daughter/custodial child while any of us is participating in a dot art program, I hereby consent for dot art to obtain emergency medical treatment for me or my child/custodial child. Such treatment may include anesthesia if such is recommended by attending personnel. I understand that I am responsible for any medical expenses incurred while I and/or my children are participating in or being transported to and from Dot Art activities. NON-DISCRIMINATION AND DIVERSITY Dot Art does not discriminate on the basis of age , race, creed, ethnicity, sexual orientation, physical or mental ability. In fact, one of its goals is to unite many different kinds of people through the artmaking process. REGISTRATION All classes are filled on a first-come first-served basis. You are officially enrolled when your payment and registration form are both received. We will notify you only if the course is full or cancelled. Published fees cover instruction and materials, unless otherwise noted. CANCELLATION Dot Art reserves the right to cancel or substitute programs and to delete portions of programs. REFUNDS Full refunds will be mailed if the course is cancelled. Please understand that our small class sizes mean that for last-minute withdrawals we cannot refund fees except in dire emergencies. VACATION & SNOW DAYS Unless otherwise stated, Dot Art follows the Boston Public School Schedule for vacation and snow days. I hereby for myself, my heirs, executors, and administrators waive and release any and all rights and claims for damages I may have against dot art and/or teachers, staff, board of directors and trustees. * Agree Disagree By initiating below, I am in effect signing my name in agreement with the above paragraph. * Thank you!
