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Fayette County Cultural Trust/ArtWorks Connellsville Summer Art Workshops 2013 Registration Please return this form to: ArtWorks Connellsville 139 West Crawford Avenue, Connellsville, PA 15425 724-320-6392 Due to space and optimum instructor to student ratio the number of students registered in the program is limited to 12 participants per class. Classes will be held at 139 West Crawford Avenue Connellsville, PA 15425- 724-320-6392 One form per student. Please Print. Student’s Name:_________________________________________________________ Address:_______________________________________________________________ City:____________________________ State:_____ Zip:______________ E-mail address:__________________________________________________________ Daytime Telephone Number: ___________________________________ Alternate Telephone Number: ___________________________________ School attending:_____________________________________________ Grade:____________ Student’s age:_____________ Gender:__________ Parent or Guardian’s Name:_____________________________________ (___) Check here if information is same as above. Address:______________________________________________________ City:____________________________ State:_____ Zip:______________ E-mail address:________________________________________________ Daytime Telephone Number: ___________________________________ Alternate Telephone Number: ___________________________________ Emergency Contact Name:_____________________________________ Emergency Contact Telephone:_________________________________

Fayette County Cultural Trust/ArtWorks Connellsville 2013 Summer Art Workshops Summer Art Camp Policies Photographs We periodically take photos of students working in class or with their finished products. These photos may be used on our websites ( & If you do not want photos included on the website, please let us know at the start of class. Only first names will be used with the photos. Expected Behavior All participants are expected to behave in an appropriate manner while in the class. We will work with each child to make sure that he/she understands the rules and expectations. We reserve the right to ask any child to stop attending classes if they have shown an unwillingness to follow the rules. Child and Project Pick-up We reserve the right charge an additional fee to keep your children past their class period. Please be prompt! Finished projects will be kept for two weeks after you are given notice that they are ready for pick up. Hold Harmless Agreement I hereby release, hold harmless, defend and indemnify Fayette County Cultural Trust, Summer Art Camp, their affiliates, officers, members, agents, employees, and other participants from any and all damages, injuries, claims and causes of action which may accrue to or be asserted by me or any minor child of mine arising directly or indirectly out of my minor child’s participation in art classes/activities at Summer Art Camp. I also give my permission to the aforementioned organization for the free use of my likeness and that of my child or ward, in connection with any broadcast, telecast, print media or other publicity. The undersigned hereby forever releases, discharges and covenants to hold harmless Fayette County Cultural Trust and teachers from any and all claims, demands, damages, costs, expenses, loss or services, actions and causes of action belonging to the undersigned or arising out of any act or occurrence in connection with and particularly on account of all personal injury, disability, property damage, loss or damages of any kind sustained or that may hereafter be sustained arising out of the matters described herein. Permission to Provide Emergency Medical Treatment I authorize Michael Edwards to organize any required medical or first aid procedure, or to take the undersigned student to the hospital emergency room for treatment. I understand that every effort will be made to notify me or individual indicated as emergency contact beforehand by telephone. This Release and Hold Harmless Agreement shall constitute a full and complete release of any and all claims for all classes taken on or after the undersigned date. PARTICIPANT NAME___________________________________________________________

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2013 ArtWorks Connellsville Summer Workshops