Art Camp and Class with Ms. Sylvia Registration Form
Please print out this form (also available in PDF here), fill out, and return
it to Ms. Sylvia! Payment can be made with cash, check or online at DecaturArtClasses.com
Child's Name:
_________________________________________________
Child’s age:
____________________________________________________
Parent(s) name(s): __________________________________________
Parent(s) phone
#(s): _______________________________________
EMERGENCY CONTACT
#(s):________________________________
Adults authorized to pick up child, if
different from parent(s):
________________________________
Child’s allergies and/or any dietary restrictions:
_________________________________________________________________________
Child’s doctor & doctor’s phone
#:_________________________________
Child’s health insurance: ______________________________________
Number of weeks registered?
_____________________________________________________________________
Which weeks? _______________________________________________
Number of days of optional extended
lunch? ___________________________________________________
Other information:
_________________________________________________________________________
Ms. Sylvia Cross, 404-660-9967, Ms.Sylvia.Cross@gmail.com ,
Sycamore Place Gallery, 120 Sycamore Place,
Decatur, GA 30030
Informed Consent:
Art Camp with Ms. Sylvia
I grant my child,
______________________________________________, permission to participate in
the art class and/orcamp program run by Sylvia Cross at Sycamore Place Gallery.
In doing so, I accept the following
program conditions:
Only authorized persons will be allowed to pick up my
child(ren). Authorization requirements for escorts other than legal guardian
parents include filing parental consent and photo identification of the escort
with Sylvia Cross at Sycamore Place Gallery prior to the date of pick up.
Telephone authorizations are not
accepted as valid authorization.
Children are not allowed to enter or leave the
building without being escorted by their parents or person authorized to drop
child off or pick the child up.
This program will consist of planned group and
individual activities as well as opportunities for free play both indoors and
outdoors.
This program will focus primarily on
art, art activities, creative expression and art education.
Qualified staff will be present at all times in staff
to child ratios meeting appropriate state regulations. My child will be served
an afternoon snack as a part of this program. Program personnel will prepare
these snacks and menus will be available to me.
If there are field trips using a
motor vehicle separate written consent will be obtained from me.
Photographs will be taken only with the express
permission of the Program Director. Photographs will be used for such purposes
as publicity, media reports on the program, and art projects by the students in
the program. I will be asked for permission before my child is specifically
identified in a published photograph. Before any medication is dispensed to my
child, I will provide a written authorization, which includes: date, name of
child, name of medication, prescription number, if any, dosage, and date and
time of day medication is to be given. Medicine will be in the original
container with my child’s name marked on it.
In cases of illness, I will be called
and possibly required to pick up my child(ren) as soon as possible.
Sylvia Cross at Sycamore Place Gallery personnel will have
current First Aid and CPR training certification at all times while my child is
enrolled in the program.
Informed Consent, Art Class and/or Camp
with Ms. Sylvia (continued)
In cases of simple injury, (such as abrasion, skinned
knees, splinters, etc…) the program staff will perform routine hygienic
measure, such as washing wounds and applying bandages. I will be informed when
I arrive to pick up my child(ren) about these incidents and the actions taken.
These routines may also include the application of first aid products in the
event of burns or need to protect against infections. In the event of a
bee sting or other stings antihistamines will be given
orally. I will inform the Sylvia Cross at Sycamore Place Gallery staff of all
known allergies of my child(ren).
In case of medical emergency, I will be
called and will take responsibility for obtaining the necessary medical
treatment.
If circumstances require immediate or professional care (in
the judgment of the program staff) program staff will call an Emergency Medical
Service (EMS). The program staff will respond as necessary until EMS arrives.
In the event emergency treatment is required, I give consent for my child(ren)
to be taken to a nearby medical facility and if necessary for treatment by a
qualified physician. Program staff will not transport my child(ren) to an
emergency facility. An EMS driver or I, myself will transport my chil(ren) to
an emergency facility. Cost incurred from treatment of any injury or illness
occurring within the program is my responsibility. Records concerning my
child(ren) will not be released unless requested by me in writing. All records
are kept confidential.
To the best of my knowledge, my Child(ren) has/have
no condition which restricts his/her full participation in the Sylvia Cross at
Sycamore Place Gallery program. If in the future any restrictions are
necessary, I will inform the Sylvia Cross at Sycamore Place Gallery program in
writing.
The Sylvia Cross at Sycamore Place Gallery program will
operate according to a risk management plan designed to protect children from
any danger of abuse or neglect. Program staff is required by state law to
report to the appropriate authorities any suspicion that a child has been
abused or neglected or is in danger of abuse or neglect.
Parents are responsible for keeping the program
advised of any significant changes in the information that they provided at the
time of enrollment concerning numbers, work locations, emergency contacts,
family physician, et
I have read and agreed to abide by
the terms listed in the informed consent.
Parent/Guardian_________________________________________
Date ___________________
Parent/Guardian________________________________________
Date____________________
Program
Director____________________________________________ Date___________________
