Youth Summer Camps Please complete one form

Registration Form—Page 1 of 2 for each student

Child Name Date of Birth Age

Parent/Guardian Name

Child’s Address City/State Zip Phone Email

Address City/State Zip (if different than student)

Emergency Contact Phone (other than Parent)

Allergies Medications

Other Pertinent Info (including social & behavioral concerns)

Can you child have food shared by other students or parents? q Yes q No

List all other persons authorized to pick up your child:

Name Phone Relationship

Name Phone Relationship

Name Phone Relationship

Name Phone Relationship

Name Phone Relationship

Has student been exposed to contagious or infectious diseases in last six months? q Yes q No

If yes, list disease and date of exposure

Are student’s immunizations up to date? q Yes q No Date of last Tetanus Shot

Name and Phone of Student’s Physician

Signature

Date

Check in: Parents/guardians will check their child in and out through the Iowa Street entrance. Your fingerprint scan will admit you and your child to the CFABS campus. Drop off procedure: First day of class, parents/guardians are shown where their child’s classroom is located. Children may be dropped off at their classrooms for the rest of the course session. Pick up procedure: Pick up is promptly at the end of the course, at your child’s assigned classroom space. Please be on time, we do not have the extra personnel to care for your child when he/she is not in class. Parents/guardians that continually arrive after the final scheduled pick up time may incur additional fees. For your child’s safety: If regular parent or guardian cannot pick up your child, please provide advanced signed written permission for the release of your child to another adult’s custody. Also, please provide signed written permission for the release of your child if she/he is to be allowed to walk or bike home from the Centers. Attendance policy: If your child is going to be absent, please call the front desk to notify us 239-495-8989. Emergency communication: If you need to contact your child during class, please call 239-495-8989. Medications, First Aid & Safety: If your child needs to take prescribed medication, please see our front desk personnel. Medications are kept under lock and key and dispensed by staff following parent/guardian’s written instructions. Toilet Training Policy: All children must be toilet trained before entering CFABS programs. Children must be able to clean themselves without teacher assistance. If your child has an accident that must be addressed during class, you will be called to come at once and provide clean clothes. Please know that this is for health, safety and legal concerns to protect both your child and the teacher. Medical Issues: For your child’s protection in the case of any medical issues, parents are always notified via cell phone, and, in emergency 911. It is important we have primary and secondary emergency cell numbers for your child. Media Release: Photographs and video taken either as the Centers for the Arts Bonita Springs or media documentation of ongoing programs and performances have parental and/or guardian approval with this completed Registration Form and enrollment in noted courses and performance productions. This includes performances at the Centers for the Arts Bonita Springs as well as any offsite promotional photos or videos produced. Email Usage: The Center for the Arts Bonita Springs will include your email address in our regular Art Center News announcements informing you of upcoming activities, events, classes and opportunities. You may unsubscribe at any time. Your email address will not be shared or disclosed to any outside entity.

I, the undersigned, will indemnify and hold harmless the Centers for the Arts Bonita Springs, its employees, volunteers and any other representative, from and against any and all actions, in law or in equity, from liability or claims for damage or judgments to any person or property that may result now or in the future from the conduct of this event.

Furthermore, I do hereby release, discharge and hold harmless the Centers for the Arts Bonita Springs, its employees, volunteers and any other representatives, of and from any and all claims, demands, actions, causes of actions and suits at law or in equity for and on account of any injuries, damages or accidents sustained by me (or my child) while participating in or being a spectator of any activity or event sponsored by the Center for the Arts Bonita Springs. I know that in participatory activities, injuries may occur, and I understand all injuries sustained and costs incurred therein must be paid by my personal insurance company or by me. I understand that this release includes any claims based on negligence, action or inaction of the Centers for the Arts Bonita Springs, its staff, directors, volunteers, members and guests.

The undersigned has read and voluntarily signed the release and waiver of liability and Indemnity Agreement, and further agrees that no oral representations, statements or inducements apart from the foregoing written agreement have been made.

The Centers for the Arts Bonita Springs is not responsible for the supervision of children arriving on site prior to or remaining on site after the established program time, unless enrolled in a before or after class program. If you or your family has special needs, please let us know by contacting the President or the Education Director.

In signing this agreement, I acknowledge and represent that I have read and understand this document, that I sign it voluntarily and that no oral representations, statements, or inducements have been made. I am at least eighteen years of age and fully competent. I understand that I am giving up substantial rights by signing this document and voluntarily agree to be bound by it. This form may not be signed electronically, must be physical (wet) signature by parent/guardian.

Signature Date Have a CFABS Family Membership? q Yes q No

PAYMENT: q CASH q CHECK # payable to: Centers for the Arts Bonita Springs

CREDIT CARD: q VISA q MASTERCARD q DISCOVER q AMEX

Print Name (as it appears on the card)

Signature

TOTAL:

Card Number

Youth Education—Cancellation, Transfer & Refund Policy: If you are going to cancel or transfer your child out of a course, please let us know at least a week prior to the start date. All transfers and refund requests will incur a $10 fee. There is a 25 percent fee for cancellations received less than 7 days prior to the start of the course. If you request a refund after the course begins, you will only receive a 50 percent refund of the remaining sessions in the course. No refunds or transfers will be allowed after the final course.

Please return this completed form to either CFABS location: Performing Arts Center, 10150 Bonita Beach Rd, Bonita Springs, FL 34135 · Visual Arts Center, 26100 Old 41 Rd, Bonita Springs, FL 34135

If you or your family has unusual circumstances (i.e. loss of employment) that might affect need for student aid, submit this form and consult the Centers’ President. This confidential form is used for the sole purpose of awarding scholarships to students in need of financial aid. No part of this form may be processed/disclosed to anyone other than the Centers’ President, Education Director or Financial Officer.

PARENTS OR GUARDIAN OF STUDENT, PLEASE ANSWER THE QUESTIONS BELOW:

Student’s Full Name q Adult q Child

Guardian’s Full Name (If student is a Child) Relationship

Family’s permanent address City State Zip Email

Family’s Permanent Phone No. Daytime Evening

Driver’s License No. (If student is a Child, provide Guardian’s)

Are you a U.S. Citizen? q Yes q No. State of legal residence . Do you q OWN or q RENT your home?

If the student is a minor, is he/she an orphan, ward of the court (foster care, etc.)?

What was your and spouse’s adjusted gross income for last year?

PLEASE PROVIDE A COPY OF YOUR IRS FORM 1040 WITH THIS APPLICATION.

Enter your tax exemptions. Exemptions are on IRS Form 1040

Parent’s Marital Status as of today? q Married q Single q Divorced/Separated

How many people in your household?

Children’s Ages: _______, _______, _______, _______

Mother’s Name Social Security No.

Father’s Name Social Security No.

Adult Student’s Social Security No. (If applicable)

Any special circumstances we should consider calculating your discount/scholarship?

This information is true and correct to the best of my knowledge.

Signature of Guardian or Adult Student Date

Financial aid awards are calculated on the classes in which the students enroll and any costs of materials or equipment for those classes. Scholarship dollars are based upon a formula for financial assistance to enroll and complete classes/programs with the Centers for the Arts.

Total amount awarded: $

Total amount of Applicant’s portion: $

Signature of President Date

Email this application and a copy of your IRS 1040 form to controller@artsbonita.org or return to either CFABS locations: Performing Arts Center, 10150 Bonita Beach Rd, Bonita Springs, FL 34135—OR—Visual Arts Center, 26100 Old 41 Rd, Bonita Springs, FL 34135.

If you have any questions, please call 239-495-8989.