Registration Form

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 (if applicable)

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: