AN INVITATION TO APPLY

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1 Fall Family Focus at the Museum of Contemporary Art Jacksonville AN INVITATION TO APPLY This fall the Museum of Contemporary Art Jacksonville will continue Rainbow Artists: Art and Autism across the Spectrum, an education initiative designed to address the needs of children with autism spectrum disorders. The goals of Rainbow Artists are to: 1. Improve social skills and involvement of peers within an art setting, using art-making as an instrument of communication 2. Foster the development of creative art-making skills, using a variety of art mediums and subjects 3. Increase familiarity and acceptance of new sensory stimuli through the use of multiple art materials with varying textures, smells, shapes, colors, and sounds 4. Provide experience in an art museum setting that will enable children to explore art in the galleries, enjoy interactive time with peers and artmaking time in MOCA art studios The Rainbow Artists Fall Family Focus is for 14 children ages 6 12 with ASD and their attending family members. MOCA educational staff and an autism consultant will work directly with the same 14 children on Saturday mornings for six biweekly sessions of individual and collaborative art-making. As the children s program proceeds, the attending adult family members will have their own program occurring separately, providing a constructive forum and support atmosphere led by an outside consultant at the Jacksonville Main Library. All student participants will receive a Certificate of Merit. In addition to MOCA education staff, the participants in the Rainbow Artists Fall Family Focus will be supervised by Sarah Beaman, MAAT-ATR. A registered art therapist for eight years, Sarah has been an ESE teacher in the Duval County Public Schools for two years and is MOCA s consultant to insure the project is designed and administered appropriately for the children involved. Space is limited. Applicants will be notified by telephone and writing as soon as possible to confirm participation. Fall Family Focus Session Dates Saturdays from 10:30 am 12:00 noon: October 11, 18 November 1, 15 December 6, 20

2 Registration Form Student s Last Name First Name Pricing: $120 for Non Members / $100 for Members $ Contact mocajacksonville.org/membership or x225 for Membership Levels and Prices YES! I would like to contribute an additional donation to MOCA Jacksonville s Education Department! $ TOTAL AMOUNT $ I will pay with a check made payable to MOCA Jacksonville enclosed. Please charge my credit card: Visa MasterCard American Express Discover Name as it appears on the card Billing Address City State Zip Acct# Expiration Date Three Digit Code Three Digit Code is located on the back of the credit card on signature line. Signature

3 Application Form Student s Last Name FirstName DOB Age Gender Grade School Spaces are limited for this program. In order to assure a positive experience for your child, applications for Rainbow Artists will be assessed on the following criteria: Student must be able to initiate requests verbally or with the use of an adaptive communication device. If camper uses an adaptive communication device that device must come with the camper each day. Student must be able to attend to task at hand or be able to request a break when and if needed Student must be able to tolerate a wide variety of art materials without allergic reactions or be able to tolerate wearing gloves for extensive art making periods Contact Information Father s Last Name FirstName Phone (H) (W) (Cell) Mother s Last Name First Name Phone(H) (W) (Cell) Student resides with: both parents father mother other Mailing Address City State Zip

4 Rainbow Artists: Art and Autism Across the Spectrum Media Release Photographs or video may be taken of students during classroom and gallery time. The Museum will use these images only for staff use or in house publications; for example FORMA newsletter, MOCA website, School Tour Brochure and other advertisements. As well these images may be used for community publications; for example Florida Times-Union, Folio Weekly and Downtown This Week. I do accept for images of my child to be used for museum and community publications. I do not accept for images of my child to be used for museum and community publications. Printed Full Name of Parent or Legal Guardian Signature Date

5 Rainbow Artists: Art and Autism Across the Spectrum Liability and Medical Release I, the undersigned parent or legal guardian, do hereby release MOCA Jacksonville the employees, volunteers and trustees from any and all liability, cost or expense associated with any injury sustained by any member of my family while participating in MOCA Jacksonville s programs. Furthermore, the undersigned agrees that in the event that medical attention is required due to accident or illness, MOCA Jacksonville shall be permitted to seek such medical services as it shall deem necessary and appropriate through Emergency Medical Attention, 911 and or local hospitals and the undersigned will be responsible for all expenses of such care. MOCA Jacksonville will not administer any medications without written instructions and parental signature. Printed Full Name of Parent or Legal Guardian Signature Date Insurance Company Policy # Emergency Contact Person Phone(W) (H) (C) Relationship to the child Child s Allergies Other information MOCA Jacksonville should be aware of (physical, emotional, psychological or behavioral)

6 Rainbow Artists: Art and Autism Across the Spectrum Drop Off and Pick Up The group will gather at MOCA on the first floor in the Atrium. Guardians will drop off students in the Atrium, and then proceed to the Jacksonville Main Library. Students will be picked up after class in the 5 th floor studios of the MOCA Education Center. Who is authorized to pick up the student? Name Phone Relationship to student Name Phone Relationship to student Name Phone Relationship to student Under no circumstances will the student leave the premises of MOCA Jacksonville with someone not authorized to pick up the student. I have read and understand the media, medical and liability release. I have provided information to MOCA Jacksonville contained on this wavier truthfully. Parent Signature Date Student Signature Date

7 For additional information, contact Kelly Eason at x207 or Fall Family Focus and Rainbow Artists Policies Participating Rainbow Artists must: Be able to initiate requests verbally or with the use of an adaptive communication device. If student uses an adaptive communication device that device must come with the student each day. Be able to attend to task at hand or be able to request a break when and if needed Be able to tolerate a wide variety of art materials without allergic reactions or be able to tolerate wearing gloves for extensive art making periods Art-Making Attire Your child will be in a studio-based art-making experience, using materials in a safe and creative manner. Please remember to dress for mess. Behavior Policy Rainbow Artists must adhere to all Museum policies and procedures. If student becomes aggressive (i.e. hitting, kicking, biting etc.) during stressful times or with transitions they may be asked to leave the camp program. Fall Family Focus Session Dates Saturdays from 10:30am 12:00pm: 10/11, 10/18, 11/1, 11/15, 12/6, 12/20 Collection of Artwork for Autism Awareness Exhibition During the month of April, 2009, MOCA would like to showcase an exhibit of artwork from the Rainbow Artists program in honor of National Autism Awareness Month. We ask that you consider lending to the Museum examples of artwork your child makes during Fall Family Focus for this special exhibition. Please detach and keep this page for your records.

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