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Registration Form

Children Camps

VISUAL ARTS MISSISSAUGA REGISTRATION FORM FOR CHILDREN CAMP
Mail this form to: Visual Arts Mississauga 4170 Riverwood Park Lane Mississauga, ON L5C 2S7 Or Fax to: 905-277-4340 Date: _______________________	Are you a member of Visual Arts Mississauga? Yes ____ No ____	Become a member of Visual Arts Mississauga! Annual child/teen membership costs $10.00 and runs from August 1 - July 31 the next year. Note: If your child is 6 years old, proof of age must be submitted with this form.

Extended Hours $5.00 per half hour (circle day and time required)

8:00 - 8:30 4:30 - 5:00 5:00 - 5:30 Mon Tues Wed Thurs Fri

Code	Date	Time Regular hrs	Fee $175 per child
		8:30 am - 4:30 pm
		8:30 am - 4:30 pm
		8:30 am - 4:30 pm
Course fees must be paid in full at the time of registration. Method of payment:
			Total $ Ext. Hours ($5.00/half hour)
			TOTAL PAYABLE
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Please complete health questions below

Emergency Contact and Phone #:

State if participant is under any form of treatment or medication:

List allergies (circle appropriate answer)

Peanuts Yes No

Emotional/Behaviour concerns:

Method of payment: Cheque____________ (make payable to Visual Arts Mississauga)

Visa or MC# ______________________________ exp:___________________

Bee Stings: Yes No

Carries EPI pen: Yes No

Medications (please name)

Other

Print out and complete the form, then mail or fax to Visual Arts Mississauga.

Remember to send proof of birthdate (e.g. copy of birth certificate) if your child is 6 years old.

Please note that the Summer School of the Arts program is repeated every three weeks.



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