Mentorship Application - First City Art Center

Student Section

Student Name*

First

Last

Grade:*

Phone:

Email:

What school do you attend?*

How did you hear about the program?*

Tell us about your interest in art/craft.*

Tell us why you are interested in learning about ceramics.*

What are your current and past extracurricular activities?*

Do you think you will have time to attend all the classes?

Yes
No

Parent/Guardian-Please Complete

Parent/Guardian Name*

First

Last

Parent Phone*

Parent Email*

2nd Contact in Case of an Emergency*

First

Last

2nd Contact Phone Number*

Are there any considerations that we should be aware of in order to better serve your child, such as allergies, medications, behavioral, sensory, fears? Any physical, visual, hearing, or motor skill limitations?

Consent and Acknowledgement

In consideration of my child’s participation in programs provided by First City Art Center, I indemnify and hold First City Art Center and its affiliates, employees and agents harmless from and against any and all liability for negligence or medical expenses resulting from my child’s participation in such programs or other activities. I further release First City Art Center and its affiliates, employees and agents from any and all negligence or other claims resulting from my child’s participation. I further understand that First City Art Center does not provide medical insurance coverage for my child and that any medical expenses incurred will be paid by either my own medical insurance or myself. I hereby grant permission for my child to participate in all activities.

I give permission for my child’s photo and/or likeness to be retained and used by Frist City Art Center without any remuneration or compensation.

I authorize FCAC staff to administer immediate and emergency medical treatment, including (1) transporting your child to a hospital emergency room or (2) calling the local rescue squad or ambulance.

I give permission for my child to visit the art park during breaks. The art park is located directly across from the main entrance of FCAC at 1060 N Guillemard Street.

Student Code of Conduct

Consequences include time out, notifying parents, and or in the extreme case removal from the program for the safety and well-being of all parties.

Physical harm to self or other campers
Conduct which constitutes harassment or bullying
Refusal to follow instructions to the point of threatening the safety of their-self or other campers.
Disrespectful behavior or language toward the instructors or other participants.
Theft of property
Intentional destruction of property.

Cancellation Policy

Scholarship recipients who cancel less than 7 days before class starts (exception for emergencies and illness) will not be considered for future opportunities.

Scholarship recipients who only attend the program partially with no notice or explanation will not be considered for future opportunities.

Policy Agreement*

In the field below indicates that you have read, understand, and agree to the Consent and Acknowledgment Terms and the Cancellation Policy.

I Agree