Camp Registration Form Please fill out this form for your camper. The Camp Registration Form collects important information like emergency contacts. Our COVID19 Class Policy can be found here. Please call 610-326-2506 or email us with any questions. Camp Attending*Camp Click the plus icon to enter additional classes/start dates.Student Name* First Last Student Age*Parent/Legal Guardian NamePlease enter the parent/legal guardian name if student is a minor. First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School District you reside in Home PhoneCell Phone*Email* T-shirt Size* SunscreenWe recommend sending sunscreen and/or bug spray with your child for these times we are outside. ArtFusion 19464 has my permission to help my child apply these items as needed. Yes No Would you like to be added to our email newsletter?* Yes No Please check any item we need to be aware of. (This information will be kept confidential and is important for us to know.) Allergies Medication Needed Behavior Medical Issues Other If you checked any options above, please explainEmergency ContactPlease list at least one emergency contact. This should be a different person from the parent/guardian listed above.First Emergency Contact Name* First Last Relation* Phone*Second Emergency Contact Name First Last Relation PhoneArtFusion 19464 reserves the right to take pictures of students and/or students’ work for promotional materials.* Yes, you may use photos of me/my child. No, please do not use and photos of me/my child. Class and Summer Camp Policies* By checking here, I acknowledge I have read and understood the COVID 19 and class policies. Consent and Release for Parents and Guardians of Minors I, on my own behalf and on behalf of my son/daughter/minor child, hereby allow such Student for whom I am the legal guardian, to participate at an ArtFusion 19464 Art Class (hereinafter referred to as “Art Class”) sessions. In consideration of ArtFusion 19464 making this opportunity available to the Student, I hereby agree to release, indemnify and hold harmless ArtFusion 19464 (and their officers, employees, agents, volunteers, and Board Members), from and against any and all claims, demands, liabilities, losses or expenses, including attorney fees, and including injury to Student or other party, associated with Student’s participation in Art Class (including but not limited to those arising in connection with field trips, and any transportation to and from such field trips, the use of the School’s equipment or facilities, and those arising from any act or omission of third party due to student’s own conduct). By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that the student may be exposed to or infected by COVID-19 by participating at ArtFusion 19464 Art Class. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless ArtFusion 19464, and their officers, employees, agents, volunteers, and Board Members, of and from any Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to the COVID-19 disease. I further agree that is any part of this agreement is found by a court or other appropriate authority to be invalid, the remainder of the agreement nevertheless will appropriate authority to be invalid, and the remainder of the agreement nevertheless will remain in full force and effect. I further acknowledge that I have read and understand this Consent and Release, and voluntarily agree to be legally bound by its terms.Consent and Release Acknowledgement* I acknowledge that I have read and understand this Consent and Release, and voluntarily agree to be legally bound by its terms. Medical Waiver for Parents and Guardians of Minors* I hereby grant ArtFusion 19464 (and their officers, employees, agents, volunteers, and Board Members), permission, at their discretion, to seek and authorize emergency medical treatment for my child and I hereby agree to assume all medical costs incurred. I have attached any additional medical information, that ArtFusion 19464 need by aware of, about my child to this form. Additional InformationHow did you hear about ArtFusion 19464? Online search Friend Walking by Other If you chose Other, please elaborate.If you were referred to us, whom can we thank? Would you consider volunteering for our non-profit art center? Yes No In what capacity could you best assist?Additional CommentsCaptchaPlease enter the CAPTCHA code above.