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KIDS SCULPTURE CAMP
Registration Form
TO BE FILLED OUT BY PARENT OF CHILD.

Print, fill out, send with check or credit card information. Questions, 1-210-696-9813; gilbertebarrera@gmail.com. Address to: Sculptors Academy, 11354 Vance Jackson Rd., San Antonio, Texas 78230

Contact Information

Main Emergency Phone: _________________________________________________

Childs Name: __________________________________________________________
Childs Gender: _________________________________________________________
Childs Age: ___________________________________________________________
Childs Birth month, day, year: _____________________________________________
Childs Address: ________________________________________________________
Childs School Name: ____________________________________________________

Mothers Name:__________________________________________________________
Address:_______________________________________________________________
City: __________________________________________________________________
State: _________________________________________________________________
Zip Code:______________________________________________________________
Phone: (____)_____-________
Cell phone: (____)_____-________Other___________
E-mail: _______________________________________________________________
Website: ______________________________________________________________
Face book: ___ yes ___ no; Other Social Site?_________________________________
Occupation:____________________________________________________________

Fathers Name: _________________________________________________________
Address:______________________________________________________________
City: _________________________________________________________________
State: ________________________________________________________________
Zip Code:_____________________________________________________________
Phone: (____)_____-________
Cell phone: (____)_____-________Other___________
E-mail: ________________________________________________________________
Website: ______________________________________________________________
Face book: ___ yes ___ no; Other Social Site?_________________________________
Occupation:____________________________________________________________

TO WHOM SHOULD BILLING BE SENT ?
_____________________________________________________________________
NAME
_____________________________________________________________________
ADDRESS: STREET OR BOX #
_____________________________________________________________________
CITY STATE ZIP

Childs Medical and Alerts Information

IN CASE OF MEDICAL EMERGENCY, I HEREBY GIVE PERMISSION TO THE MEDICAL AUTHORITIES, EMS AND DOCTORS SELECTED BY THE CAMP TO SECURE PROPER EMERGENCY MEDICAL CARE AND TREATMENT FOR MY CHILD, NAMED ABOVE. (THIS PERMISSION IS REQUIRED BEFORE ADMITTING A CHILD TO THE KIDS SCULPTURE CAMP)

SIGNATURE OF PARENT___________________________________________________________________________

DATE ___________________________________________________________________________________________________

MEDICAL ALERTS OR CONDITIONS OF MY CHILD THAT EMS, EMERGENCY TECHNICIANS OR DOCTORS SHOULD KNOW ABOUT: ___________________________________________________________________________________________________
___________________________________________________________________________________________________

CHILDS SPECIAL FOOD OR DIETARY ISSUES? ____________________________________________________________

ALLERGIES? __________________________________________________________________________________________________

WOULD YOU ABLE TO VOLUNTIEER?

YES         NO

IF YES, FULL TIME?________ OR PART TIME?____________ WHAT HOURS?_____________________________

WHAT DAYS? MONDAY TUESDAY WENDSAY

FROM WHOM DID YOU HEAR ABOUT THE KIDS SCULPTURE CAMP (NAME & ADDRESS)?