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