Manchester Craftsmen's Guild: Summer Studios Enrollment Form

Manchester Craftsmen’s Guild: Summer Studios Enrollment FormSummer 2011 © 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation Page 1 / 6zPlease [1] check the camp session(s) in which you are enrolling your child; and [2] theprice corresponding to your application submission date and/or package option(s). Then[3] record your costs in the Payment Calculator to determine your total due.This program is CYF eligible. Students must register with these forms through theircaseworker.Note that a child without proper paperwork will not be permitted into MCG’s facilities. Bothregistration forms and all four pages of parent/guardian signed forms and waivers must becomplete and submitted to MCG at least 1 week prior to programming. We stronglyencourage you to complete and mail all forms at the same time as payment.Programs for Middle School Students (rising 5th – 8th graders between 10 –13 years old) $480 eachSession 1 (Studios: Photo, Design, Digital)Monday – Friday, July 5 – July 15, 2011 from 9 a.m. – 4 p.m. (MCG is closed on Monday, July 4)Session 2 (Studios: Digital, Design, Ceramics)Monday – Friday, July 18 – 29, 2011 from 9 a.m. – 4 p.m.Session 3 (Studios: Digital, Photo, Ceramics)Monday – Friday, August 1 – 12, 2011 from 9 a.m. – 4 p.m.Programs for High School Students (rising 9th – 12th graders between 14 –18 years old) $250 eachPottery Plunge (Studio: Ceramics)Monday – Friday, July 5 – July 15, 2011 from 1 – 4 p.m.(MCG is closed on Monday, July 5)Flashin’ Fashion (Studio: Photo)Monday – Friday, July 18 – 29, 2011 from 1 – 4 p.m.Fresh Fashions (Studio: Design)Monday – Friday, August 1 – 12, 2011 from 1 – 4 p.m.

Manchester Craftsmen’s Guild: Summer Studios Enrollment FormSummer 2011 © 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation Page 2/ 6[4] Payment CalculatorTotal for Selected Day Camps for Middle School Student: $Total for Selected Day Camps for Afternoon “Boot Camps” for Teens: $If you are a caseworker registering a CYF child, please print ’CYF’ in TOTAL TOTAL = $Registration Details (Full payment is required to reserve a space in each session.)Forms and Waivers* We strongly encourage you to complete and mail all forms at the same time as payment. Parent/guardian signed formsand waivers must be complete and submitted to MCG at least 1 week prior to programming. A child without properpaperwork will not be permitted into MCG’s facilities.Enrollment Capacities and Eligibility Requirements* Registration will be accepted until sessions fill. Waitlists will be maintained once a session has reached its capacity.* A $10 non-refundable fee is required to be on a waitlist.* Programming is designed for the designated age ranges. Children who do not meet the age requirements at time ofregistration, will not be permitted to participate:* Middle School Programs: 10 – 13 year olds (rising 5th – 8th graders)* High School Programs: 14 – 18 year olds (rising 9th – 12th graders)* MCG is dedicated to educating and inspiring all youth through the arts. While we will strive to accommodate any childrenwho have special needs, please understand that our ability to adjust materials, curriculum, and activities may be limited.Please contact us regarding any special needs that may impact a child’s participation in the camps.MCG imposed changes or cancellations* All activities and schedules are subject to change based on enrollment requirements.* Registrants will be notified of any cancellations at least 1 week prior to start of programming, and a full refund will be given.Cancellations made by registrants* By May 14 (before 5:00 p.m.), a full refund minus a $50 processing fee will be granted.* Between May 14 and June 4 (by 5:00 p.m.), a 50% refund will be granted.* No refunds will be granted for cancellations made after June 4.Payment MethodI have enclosed a check or money order payable to Manchester Craftsmen’s GuildI have already paid via credit card online at www.mcgyouthandarts.orgI plan to call MCG to pay by credit card (Rose Mary East: 412-322-1773 Ext 302). I also understand that mychild’s space is not reserved until MCG receives payment in full.Payment Notes (Please use this space for any special notes you need to communicate to MCG regarding payment):PHONE:412-322-1773 Ext. 302Please contact Rose Mary East with questions or to submit an application:FAX:412-321-2120E-MAIL:rmeast@mcg-btc.orgPOSTAL MAIL:ATTN: Rose Mary East1815 Metropolitan StPittsburgh, PA 15233

Manchester Craftsmen’s Guild: Summer Studios Enrollment FormSummer 2011 © 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation Page 3 / 6Student InformationLast Name:First Name:Birth Date:Gender: Male FemaleStreet Address:City: State: Zip Code:Student Home Phone:Student Cell Phone:Student Email:Ethnicity(check one): Caucasian Hispanic Asian Bi-Racial No Response African-American Native American Hawaiian orPacific Islander Multi-Racial Other:Student Education InformationSchool Attended in 2010 – 2011: Grade Level (2010-2011):School Attending in 2011 – 2012 : Grade Level (2011-2012): Graduation Year:Student is Eligible for (check one): Free Lunch Reduced Lunch Neither Free nor Reduced LunchParent/ Legal Guardian InformationLast Name:First Name:Street Address:City: State: Zip Code:Parent Home Phone: Parent Work Phone: Parent Mobile Phone:Parent Email:Manchester Craftsmen’s Guild admits students of any race, color, and national or ethnic origin.© 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation

Manchester Craftsmen’s Guild: Summer Studios Enrollment FormSummer 2011 © 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation Page 4 / 66Emergency Contact InformationPlease indicate the person not listed under Parent/ Guardian that MCG should notify in the event of an emergency:Last Name: First Name: Relationship to Student:Home Phone:Alternate Phone:Physician Contact My child does not currently have a physician he/she regularly visitsPhysician Name:Phone:Alternate Phone:Student Medical HistoryIt is extremely important that you provide details about any medical history and existing conditions that may affect your child ifhe/she requires treatment due to a medical emergency.Date of late tetanus vaccination:My child experiences(check all that apply): Asthma Epilepsy Bleeding Disorder Migraines Allergies (please list): Diabetes Kidney DiseaseOther physical or behavioral conditions that a medical professional handling your child should be aware of(please describe):Please list any medications your child is currently taking: NoneIs your child currently under the care of a physician for an ongoing condition? No Yes (please explain):Parental/ Guardian ConsentI understand that Manchester Craftsmen’s Guild does not have medical professionals on staff, and that MCG teachers orother staff will not administer or provide any medication to my child. I accept that in the event of an incident with my child,MCG will make every effort to get in touch with the emergency contacts in the order they are listed above. If none of thesecontacts can be reached and/or immediate emergency action must be taken, I hereby authorize MCG to secure all proper andrequired treatment deemed necessary under the then-existing circumstances to stabilize my child until such time as I can bereached to personally grant consent. I understand that the information provided on this form will only be used asneeded in the event of an emergency, that it is my responsibility to notify MCG of any changes to the informationprovided, and that my failure to return a signed copy assumes consent.Parent/ Guardian SignatureDate

Manchester Craftsmen’s Guild: Parental/ Guardian Consent Waiver & A/V Release FormSummer 2011 © 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation Page 5 / 6Dear Parent/Guardian,In order to participate in MCG Youth programming, we require students and their parent or guardian toacknowledge and commit to MCG Youth’s general terms and conditions—stated below—by submitting asigned copy of this form.I give my son/daughter permission to participate in Manchester Craftsmen’s Guild Youth & Arts Summer Studio program.1. I understand that my son/daughter may be working with mechanical equipment and/or chemicals as part of theircoursework in ceramic, photography, digital and design arts.2. I understand that MCG will share its Honor Code with my son/daughter and that any violations will be documentedand suspension may result if he/she consistently fails to comply with this code of conduct and the rules of the MCGprogram.3. I understand that MCG maintains an attendance policy that expects parents/students to communicate absences totheir instructors.4. I understand that MCG reserves the right to cancel classes as needed due to inclement weather, or othercircumstances that may put the safety of students and staff at risk. MCG will make every effort to communicateclosings by posting information on our website.5. I understand that MCG provides each student a photo ID, which is required to obtain entry into the facility.6. I understand that MCG is not responsible for children who arrive more than 5 minutes before scheduled drop-off orremain in the building longer than 5 minutes after the program ends. MCG reserves the right to dismiss a child fromthe program without refund if he/she abuses the arrival and dismissal policy more than three times.7. I understand MCG often arranges field trips for students as part of their class experience. These trips involve travelingoutside the MCG facility in MCG-authorized vehicles and may take place outside of normal program hours. All tripswill be supervised by MCG staff. Special information including permission slips will be administered for extended trips.8. I understand that photographs and video may be taken during MCG programming, and I understand that these mediaare important for educational, funding and promotional materials that celebrate and share accomplishments at MCG.Therefore, I give Manchester Craftsmen’s Guild and partnering organizations my permission to use, in part or whole,the name, picture, performance, photograph and/or taped voice of my son/daughter and I release the program fromany monetary compensation or from any and all claims resulting from such use. I acknowledge that MCG will makeevery effort to send, but does not guarantee, special notification when the images are intended for use by anotherorganization or institution.9. I understand that Manchester Craftsmen’s Guild cannot be responsible for any of my son/daughter’s personalpossessions that he/she chooses to bring to MCG programs.10. I understand that in order to learn how well this program is working and to make improvements, MCG staff and/orprofessional evaluators will conduct interviews, lead focus groups and administer questionnaires in which your child’sdemographic information may be included. All information will be treated confidentially and students’ names will notbe revealed when results are reported.11. I have read and agree to all terms outlined in MCG’s Summer Studios enrollment packet.12. I understand that this signed form is a release that extends to all Manchester Craftsmen’s Guild Youth activities,unless otherwise noted below by me.Students Name (Please Print Clearly):Student’s Signature:DateParent/ Guardian’s Name (Please Print Clearly):Parent/ Guardian’s Signature:Date

Manchester Craftsmen’s Guild: Honor Code AgreementSummer 2011 © 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation Page 6 / 6Manchester Craftsmen’s Guild (MCG) Youth & Arts is a center for arts and learning that educates, inspires, and supportspositive change among Pittsburgh youth by engaging students and their communities in learning through visual arts. MCG isan organization that succeeds based on five core, shared values:• Respect one another• Embrace learning opportunities• Listen with the intent to understand and respond• Influence others in positive ways• Shape solutions to problemsMore than a collection of studios, MCG is a community defined by its culture. Our community cannot thrive without mutuallyrespected guidelines that ensure a safe and productive environment where we can all work together. It is imperative thatevery individual is aware of and assumes responsibility for his/her actions and their effects on others during all relatedactivities regardless of where or when they occur.The Tenets of the MCG Youth Honor Code• I will arrive on time, attend regularly, and participate in all course activities.• I will always receive permission before using a music player, cell phone or other electronic device.• I will use time productively and work to the best of my ability.• I will respect personal privacy and property of peers, faculty and staff.• I will respect tools, equipment, MCG facilities and grounds, and use materials wisely.• I will socialize in community spaces only during scheduled studio breaks.• I will respect the Manchester Craftsmen’s Guild and Bidwell Training Center environment and others in the buildingby speaking quietly in hallways and avoiding running or horseplay, etc.• I will refrain from tobacco, alcohol or drug use and understand that violation of this rule may result in immediatesuspension from MCG programs.• I will always receive permission before eating and drinking in the arts studios.• I will remain with the class until the bus or my ride has arrived.• I will always consult an instructor before leaving the group for any reason.• I will act as a role model by demonstrating MCG’s values of respect, embrace, listen, influence, shape.I understand that participation in MCG programs is a privilege that is earned and maintained through a positive attitude aboutlearning and a genuine desire to be an active member of its community. I know that it is critical to take guidelines seriouslyand uphold them with diligence and rigor. By signing below I acknowledge my commitment to sustain MCG’s culture byadhering to the Honor Code, and I understand that violation of these guidelines will be documented and may result insuspension from MCG programs.Students Name (Please Print Clearly)Student’s Signature:DateParent or Guardian Signature:DateManchester Craftsmen’s Guild admits students of any race, color, and national or ethnic origin.© 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation