SUMMER ARTS PROGRAM 2014 Classes are held in the Museum’s galleries, outdoor courtyards, and Education Center. Advance registration is required. Class sizes are limited. Registration is accepted by mail, fax or in person only. Phone registration is not available. Enrollment can not be guaranteed until full payment is received. All children must be signed in and out of the Education Center by a parent or guardian. DAILY SCHEDULE Drop off begins at 8:00 am Morning Session: 8:30 am - 11:30 am Lunch: 11:30 am - 12:30 pm Afternoon Session: 12:30 pm - 3:30 pm Pick at 3:30 pm Aftercare: 3:30 pm - 5:00 pm REGISTRATION FORM Child’s Name_______________________________________________________________ Age__________________________ grade entering 8/14 Parent’s Full Name___________________________________________________________ Telephone (h) __________________(c) ____________________(w)___________________ E-mail_____________________________________________________________________ Address_______________________________________________City_________________ State_________Zip________Child’s Friend_______________________________________ The Museum welcomes children of all abilities. Making us aware of any special needs or considerations is greatly appreciated and helps staff and art instructors ensure a successful camp experience. Please list any known allergies/other conditions requiring special consideration: __________________________________________________________________________ __________________________________________________________________________ In case of accident or serious illness, I request that I/we be contacted. I hereby give permission for emergency medical treatment, which will include, but not be limited to, initial diagnostic x-rays and other such procedures as the physician may deem necessary for the preservation of health. I agree to assume all costs related to such treatment. I hereby waive and release Tucson Museum of Art staff, teachers, and volunteers from and against all claims and medical and legal costs associated from my child’s/children’s program participation. Date__________Signature Parent/Guardian______________________________________ If the Museum must cancel a session, full refunds will be given. Otherwise all art camp costs are nonrefundable. Don’t forget to dress for a mess or bring a smock. One registration form per child. 140 North Main Ave. Tucson, AZ 85701 · 624-2333 · fax 624-7202 SUMMER ARTS PROGRAM 2014 Please check week(s) and session(s) -6 9 ne Ju Price members/non-members $100 /$155 Morning $100 /$155 Afternoon $200 /$310 Full day 1 3 1 ne 3 27 3- 2 ne Ju Ju 2 20 6- -1 2 ne l Ju Ju 4 5 8 -1 11 y7 4 y1 l Ju 6 st 5 -2 1 y2 l Ju 7 ly Ju u ug -A 1 28 8 $20 Aftercare Total Class Fees Membership (see below) Please check here if you and/or your children do not wish to be photographed for press and publicity. GRAND TOTAL MEMBERSHIP supports Tucson Museum of Art exhibitions and education programs. Visit the website at Dual/Family $50 Sustaining $100 Patron $250 President's Circle $500 Director’s Circle $1000 Membership: New Renewal Check enclosed (Payable to Tucson Museum of Art) Credit card: MC Visa Am Ex Disc #________________________________________________________________ Exp. Date________________________ cvv code: ___________________ Cardholder’s Signature______________________________________________ 140 North Main Ave. Tucson, AZ 85701 · 624-2333 · fax 624-7202 CDC/SGH# or name:____________________ Arizona Department of Health Services Bureau of Child Care Licensing Emergency, Information and Immunization Record Card Child’s Name: Updated: Date Enrolled: Home Address (#, Street, City, State, Zip Code): Date Disenrolled: Date of Birth: Home Phone: Sex: Mother or Guardian Name: Home Address (#, Street, City, State, Zip Code): Cell Phone (optional): Contact Telephone Number: Father or Guardian Name: Home Address (#, Street, City, State, Zip Code): Cell Phone (optional): Contact Telephone Number: male female I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted: Name: Contact Telephone Number: Name: Contact Telephone Number: Name: Contact Telephone Number: Name: Contact Telephone Number: If Medical care is necessary, call: Contact Telephone Number: Health Care Name: Provider* *A Health Care Provider is a physician, physician assistant or registered nurse practitioner. I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her health and safety. It is understood by me that the expense of this service will be accepted by me. In case of injury or sudden illness, I request that this individual be called first: Does your child have insurance coverage? No Yes Name of Insurance Company: The following individual(s) may NOT remove my child from the facility: Name(s): Custody papers have been provided and are on file at the facility. Telephone Authorization Code (optional):___ yes _______ no Immunization Information (A licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and Immunization Record card.) For information regarding current immunization requirements go to: www.azdhs.gov/phs/immun/index.htm or contact the Arizona Immunization Program Office at (602)364-3630. One of these items must accompany the EIIR card at all times: Copy of current official documented immunization record attached Religious Beliefs exemption form signed by parent/guardian attached Medical Exemption form signed by physician and parent/guardian attached Signed Laboratory Proof of Immunity form attached Notification of immunizations needed sent to Parent(s) or Guardian(s): Updated immunizations received and attached: mo /day/ yr mo /day/ yr mo /day /yr mo /day/ yr mo /day/ yr mo /day /yr Medical Information No Yes Is child usually susceptible to infections and if so, what precautions need to be taken? If yes, list precautions: No Yes Is child subject to convulsions and what should be our procedure if one occurs? If yes, specify procedure: No Yes Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)? If yes, list precautions: No Yes Is child allergic to food or other substances? If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs: Additional comments: Other special instructions: This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by: Parent/Guardian PRINTED Name: SIGNED Name: G:\Forms\Emergency Information and Immunization Record Card (9/11) DATE: