Pinch Clay with Bob Doster - Rock Hill School District

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Pinch Clay with Bob Doster - Rock Hill School District

SUMMER ART CAMP REGISTRATION: 2012

CHILD’S NAME: __________________________________________________________________

BIRTH DATE: _______/_______/_______ SEX: ____MALE ____ FEMALE AGE: __________

ADDRESS: ______________________________________________________________________

CITY:_____________________________________________ STATE: ________ ZIP: ___________

EMAIL: _________________________________________________________________________

SPECIAL CONSIDERATIONS, ALLERGIES, MEDICATIONS?_________________________________

PARENT/GUARDIAN:_______________________________________________________________

HOME TELEPHONE: _________________________ WORK TELEPHONE: _____________________

HOW DID YOU HEAR ABOUT THE CAMPS? _____________________________________________

EMERGENCY CONTACT

NAME: ________________________________________ PHONE __________________________

PHYSICIAN: _____________________________________ PHONE __________________________

NAME OF CAMP #1:_______________________________________________________________

LOCATION: ___________________________________________ DATE: _____________________

NAME OF CAMP #2:_______________________________________________________________

LOCATION: __________________________________________ DATE: _____________________

Total Amount enclosed $___________ (if additional space is needed, attach another sheet)

Fees are not refundable. Make checks payable to: Arts Council. PO Box 2797, Rock Hill, SC 29732.

Members $75 Non-Members $85

Children will have a 10-15 minute break halfway through the class each day. Juice or lemonade will be served.

Children are allowed to have snacks brought from home. Due to higher number of children with peanut

allergies, please bring snacks that are peanut free. Thanks!

If child/ward (child’s name)_________________________ should require minor or major medical treatment

during participation in arts camp activities, I give my permission to the Arts Council to take my

child/ward to the emergency room of the nearest hospital, if necessary, for the administration of treatment. I,

the undersigned parent or guardian, hereby freely and knowingly waive and release the Arts Council, its agents,

employees, sponsors, and board from any and every liability and responsibility whatsoever for personal injury,

property damage, or other loss sustained by the child named above as a result of or arising out of the child’s

participation in any activity conducted by the Arts Council. I assume all risks and hazards incidental to the

conduct of the activity.

Parent’s/Guardian Signature _________________________________ Date __________________

ARTS COUNCIL OF YORK COUNTY

PO Box 2797 | Rock Hill, SC 29732

Phone: (803) 328-2787 | Fax: (803) 328-2165

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