Artbug REGISTRATION & Information Sheet
Student Name______________________________
Age _______________ Grade _________
Home / Mailing
Address_________________________________________________________
Home Phone________________________________________
Email_________________________________________
Allergies?____________________________________
Any other info______________________________
Weekly Class Wanting to Attend or
Other______________________________________
Parental and Emergency Information
Mom’s Name_________________
Mom’s Cell___________________
Dad’s Name__________________
Dad’s Cell_____________________
Emergency Contact
#1 Name _______________________Phone______________
#2 Name _____________________Phone______________
Please provide info. about individuals your child has
permission to go home with, names and relationships, any information that is helpful
including any physical limitations / restrictions, allergies, medical
conditions to be aware of, or medicine taken by your child.
I hereby give permission for my child/ children to
participate in Helene Farrar Art's programs and field trips.
I give permission to use my childʼs / childrenʼs photo in
promotional material.
In case of an accident I grant permission for my child/
children to receive medical treatment, if needed, and authorize the attending
physician to administer any necessary medical attention.
Parent / Guardian Signature,
Date: