Donate Today
Skip to content
Calendar
This Week
This Month
Past Events
Education
Adult Classes
Youth Classes & Camps
Private Art Parties & ‘Pod’ Classes for Children
Emergency and Permissions Form
Class Info & Policies
Instructor Bios
Private Classes & Mentorship Opportunities
Scholarships
Gift Certificates
2021 Camps
Exhibitions
Taplin Gallery
Upcoming Exhibits
Past Exhibits
Graves Terrace
Upcoming Exhibits
Past Exhibits
Lower Level Gallery
Upcoming Exhibits
Past Exhibits
Solley Lobby
Upcoming Exhibits
Past Exhibits
Performances
Cafe Improv
Community Stage
Community
Outreach
Public Art Projects
$5 Fridays
Community Events
Community Projects
K-12
Kids at Work
Scholarships
Support ACP
Donate Now
Corporate Partnership
Matching Gifts
Capital & Endowment
Special Gifts & Funds
Volunteer
Circle of Friends
ACP Privacy Policy
Membership
Benefits Guide & Become a Member
ArtsCARD Benefits
Annual Pride Awards
For Artists
Free Virtual Art-Making with Princeton U. Art Museum
Annual Exhibition
Artist-in-Residence
Teaching Artists
Sauce for the Goose
Propose an Exhibition
Artist Opportunities
About
Plan Your Visit
Mission
People
Reports & Plans
ADA Compliance
BLOG
Space Rental
Spaces
Rental Guide & Rates
Rental Request Form
Caterers
Floorplan
Communiversity
Event
Get Involved
Sponsorship
Event FAQs
Dining by Design
Info & Tickets
Sponsorship
Auction
Photos
Education
Adult Classes
Youth Classes & Camps
Private Art Parties & ‘Pod’ Classes for Children
Emergency and Permissions Form
Class Info & Policies
Instructor Bios
Private Classes & Mentorship Opportunities
Scholarships
Gift Certificates
2021 Camps
EMERGENCY and PERMISSIONS FORM
Please complete and submit this form prior to any minor student starting a session that will have him or her with us for three or more consecutive hours.
Student Name
*
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Date of Birth (MM/DD/YY)
*
Email Address of Parent or Guardian
*
Email is our primary form of communication, so please use an address that you check frequently.
Emergency Contacts
Please list the person completing this form as Emergency Contact 1 below.
Emergency Contact 1: Full Name
*
Emergency Contact 1: Relation to Student
*
Emergency Contact 1: Phone Number
*
Emergency Contact 2: Full Name
*
Emergency Contact 2: Relation to Student
*
Emergency Contact 2: Phone Number
*
Medical Provider
Physician Name
Physician Phone Number
Insurance Carrier
Insurance Policy Number
Insurance Group Number
Medical History
Allergies
Medications currently being taken
Is your child assigned an aide in school? *Voluntary response, but helps us prepare*
Anything else we should know? (i.e. does your child carry an EpiPen? does your child carry an inhaler?)
What school does your child attend?
Emergency Medical Release
*
Yes
No
In case of emergency, I understand that every effort will be made to contact the parents or guardians. In the event that I cannot be reached, I give permission to the physician selected by the Arts Council of Princeton to hospitalize, secure proper treatment for, and to order anesthesia or surgery for my child. I understand I am financially responsible for any expense for medical care or transportation incurred on my child’s behalf. I hereby release the Arts Council of Princeton and its employees from any responsibility for injuries or illness occurring as a result of, or coincidental to, my child’s participation in this program.
Permissions
Walking Field Trip Permission
*
Yes
No
I give permission for my child to participate in walking field trips within walking distance from the Paul Robeson Center. I understand that students will be supervised at all times by one or two adults, depending on the class size. With supervision, younger children are taken to the YMCA playground, and preteens/teens are taken to the Princeton University Art Museum and the Princeton Farmer’s Market on Thursdays. *Please note: for summer 2020 children will not be going to the YMCA playground, Princeton Farmer’s Market or Princeton University Art Museum during camp hours.
Self-Dismissal
*
Yes
No
I give permission for the student listed above to be dismissed in his or her own at the end of the day.
Please list the names and telephone numbers of all the people you authorize to pick-up the student listed above:
Photographic Image Permission
*
I give permission for the student listed above to appear in photos/videos as described below.
I have read the statement below and will email my disconsent to info@artscouncilofprinceton.org
The Arts Council of Princeton uses photographic and video images (without student names or identifiers) of classes, workshops, and events in various publications ranging from our website and newspaper articles to grant applications and annual reports. It is a vital way for us to convey the importance of our work in the community. If you do not want your or your child’s photo used by the Arts Council of Princeton, you must notify us in writing (by email to info@artscouncilofprinceton.org or by postal mail) prior to attendance in the program.