Day Camp Online Application

Application

Session Information

Our first session begins on Tuesday, September 17, 2019, and continues Tuesdays through the end of the school year. Art Minors will not operate on any day when school is closed. Sessions are from 3:00-5:00 PM

CHILD'S INFORMATION

First Name

Last Name

Birth Date

Gender

Male
Female

Address

City

State

Zip Code

How many days per month does your child miss school? (circle one)

0
1-3
4-5
6 or more

PARENT/GUARDIAN INFORMATION

First Name

Last Name

Address

City

State

Zip Code

Primary Phone

Name Associated With Number

Secondary Phone

Name Associated With Number

EMERGENCY INFORMATION

Emergency Contact's Name

Relationship to child

Emergency Phone Number

Alternate Emergency Number

Does this child have any allergies, chronic illness, or medical conditions?

If yes, please describe.

Does the child have a prescription inhaler?

If yes, please explain any instructions

INFORMED CONSENT AND ACKNOWLEDGMENT

I hereby give my approval for my child's participation in any and all activities prepared by Art Minors Inc. during the selected after school date or event. In exchange for the acceptance of said child's candidacy by Art Minors Inc., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Art Minors Inc. and all their respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected after school date or event.

Parent/Guardian e-Signature (Initials):

MEDICAL RELEASE AND AUTHORIZATION

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor's life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.
Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the above-named child in the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury. I understand that every attempt will made by the attending physician to contact me in the most expeditious manner possible. This authorization is granted only after a reasonable effort has been made to reach me.
Permission is also granted to the Art Minors Inc. and their affiliates including Directors, Instructors, and Art Volunteer Staff to provide the needed emergency treatment prior to the child's admission to the medical facility.
Released authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Parent/Guardian e-Signature (Initials):

Date

TRANSPORTATION

If your child attends Chillicothe Intermediate School, they can be bussed to Tabernacle Baptist Church. Please answer the following only if your child attends Chillicothe Intermediate School:

YES, my child needs transportation to Tabernacle Baptist Church.
NO, my child does NOT need transportation to Tabernacle Baptist Church.

Parental Responsibility For Transportation It is the parent's responsibility to pick their child up at 5:00 PM. For children who do not attend CTS, it is the parent's responsibility to have them at TBC by 3:00 PM, and parent's responsibility to pick them up by 5:00 PM.
Forms are due no later than Friday September 5. 2019.
Please return this form to us at: Art Minors, PO Box 187, Chillicothe, OH 45601 OR you may fill this form out online.
QUESTIONS? Email us at: artminorsinc@gmail.com