EmailMe Form - Older Elementary 2018 REGISTRATION FORM

EmailMeForm

ONE REGISTRATION FORM IS REQUIRED FOR EACH STUDENT.

Registration is based on Completed grade level and birthday.

OLDER ELEMENTARY:
FEE:$25 (includes all art supplies)

Must rank classes in order of preferences 1 (favorite) thru 12. Do not leave any blank
PARENT/GUARDIAN Name *
First Last
STUDENT Name *
First Last
Submit a separate registration form for EACH student.
Primary Phone *
### - ### - ####
Date of Birth *
MM / DD / YYYY
Cell Phone
### - ### - ####
Email *
Work Phone
### - ### - ####
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
School Attending
Camper T-Shirt
Last Grade Completed *
Church Affilitation
Older Elementary Students
Who have completed: 2nd, 3rd, 4th, 5th or 6th grade.
ALL CLASSES MUST BE RANKED.

*Class Preferences:
Rank 001 (favorite), 002, 003, etc. thru 012 (least favorite). *

Painting

Pottery

Art

Dance

Vocal Music

Guitar

Piano

Drama

Photography

Drawing

Quilting

Interpretive Movement (God Rods)

Because of limited students/class, not all student choices will be available. Classes are allocated based on availability
A camp photographer will be making photographs in order to document the week of MOSAIC Camp.

Please sign here if we
DO NOT have your permission
to use your child’s picture(s)
Clear
List names of siblings attending 2018 MOSAIC Arts Camp.
Medical Information
Does your child take any medications? (List below) If not please enter "none" *
Does your child have any known allergies? (List below) If not please enter "none". *
Does your child have any medical concerns? (List below) If not please enter "none". *
iF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE SPECIFY YOUR CHILD'S INDIVIDUAL NEEDS (List below) If not please enter "none". *
Emergency Contact/People who may pick up my child.
Name
First Last
Relationship
Home Phone
### - ### - ####
Work Phone
### - ### - ####
Name
First Last
Relationship
Home Phone
### - ### - ####
Work Phone
### - ### - ####
Name
First Last
Relationship
Home Phone
### - ### - ####
Work Phone
### - ### - ####
Image Verification

Please enter the text from the image:
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Painting
Pottery
Art
Dance
Vocal Music
Guitar
Piano
Drama
Photography
Drawing
Quilting
Interpretive Movement (God Rods)

ONE REGISTRATION FORM IS REQUIRED FOR EACH STUDENT.

Older Elementary Students

Medical Information

Emergency Contact/People who may pick up my child.