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
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.
Program Director____________________________________________ Date___________________