Las Cruces Museum System SUMMER PROGRAM REGISTRATION Please complete this form. One form per student please. Please write legibly. Mail or drop off: Las Cruces Museum System, PO BOX 20000, Las Cruces, NM 88004 Child s name Child s age on June 1, 2015 Parent s/guardian s Name Address Phone (Day) (Evening) Date of Program: Name of Summer Camp Program: Age Group: Cost: June 2 5 Exploring Ecosystems (MoNaS) Ages 12-14 $150 8:00 am to 4:00 pm June 9 12 Earth, Wind & Fire: Ages 8-11 $125 An Introduction to the Elements (MoNaS) 8:00 am to 12:00 pm June 9 12 Ceramics #101 Ages 5-8 $ 60 to June 9 12 Comic Book & Story Art #102 Ages 9-12 $ 60 Come create your own comic book from beginning to end. Develop characters from scratch and write an awesome adventure. (MoA) June 9 12 Ceramics #103 Ages 9-12 $ 60 to June 9 12 World Art Adventures #104 Ages 5-8 $ 60 Students will be creating mixed media art work based on the art and cultures from all over the world. (MoA)
Date of Program: Name of Workshop Program: Age Group: Cost: June 16 19 Days of the Dinosaur (MoNaS) Ages 6-8 $100 8:00 am to 12:00 pm June 16 19 Ceramics #105 Ages 9-12 $ 60 to June 16 19 Drawing & Painting #106 Ages 5-8 $ 60 Drawing and painting introduces basic drawing and painting techniques while developing and improving student s artistic skills. (MoA) June 16 19 Ceramics #107 Ages 5-8 $ 60 to June 16 19 Nature Drawing #108 Ages 9-12 $ 60 Learn how to draw nature and the outdoors, with helpful tutorials to create beautiful illustrations and drawings. (MoA) June 23-26 Earth, Wind & Fire: Ages 8-11 $125 An Introduction to the Elements (MoNaS) 8:00 am to 12:00 pm June 23-26 Ceramics #109 Ages 5-8 $ 60 to June 23-26 Teen Still Life Drawing #110 Ages 13-17 $ 60 Discover and practice the basic techniques of drawing and painting. A step by step approach to building up a still life drawning. (MoA) June 23-26 Ceramics #111 Ages 9-12 $ 60 to June 23-26 Puppet Creators #112 Ages 5-8 $ 60 Build, invent, and design different types of puppets. Then create your own puppet theater production. (MoA) June 30 July 2Youth Capture the Colorful Cosmos (MoNaS) Ages 10-14 $ 25
Date of Program: Name of Workshop Program: Age Group: Cost: July 7-10 Ceramics #200 Ages 9-12 $ 60 to July 7-10 Mixed Media #201 Ages 5-8 $ 60 Participants create unique mixed media projects inspired by exhibits in the City s Museum System. (MoA) July 7-10 World Art Adventures #202 Ages 5-8 $ 60 Students will be creating mixed mead art work based on the art and cultures from all over the world. (MoA) July 7-10 Ceramics #203 Ages 5-8 $ 60 to July 7-10 PuppetCreators #204 Ages 9-12 $ 60 Build, invent, and design different types of puppets. Then create your own puppet theater production. (MoA) July 7-10 Teen Still Life Drawing #205 Ages 13-17 $ 60 Discover and practice the basic techniques of drawing and painting. A step by step approach to building up a still life drawning. (MoA) July 14-17 Ceramics #206 Ages 5-8 $ 60 to July 14-17 Mixed Media #207 Ages 9-12 $ 60 Participants create unique mixed media projects inspired by exhibits in the City s Museum System. (MoA) July 14-17 World Art Adventures #208 Ages 5-8 $ 60 Students will be creating mixed mead art work based on the art and cultures from all over the world. (MoA) July 14-17 Ceramics #209 Ages 9-12 $ 60 to
Date of Program: Name of Workshop Program: Age Group: Cost: July 14-17 Nature Drawing #210 Ages 5-8 $ 60 Learn how to draw nature and the outdoors, with helpful tutorials to create beautiful illustrations and drawings. (MoA) July 14-17 Pet Portaits #211 Ages 9-12 $ 60 Learn the fundamental techniques of drawing and painting while creating a portrait of your fury friend. Photo of pet is required. (MoA) July 21 22 Space Weather Action News (MoNaS) Ages 8-11 $ 10 July 21 24 World Art Adventures #212 Ages 5-8 $ 60 Students will be creating mixed media art work based on the art and cultures from all over the world. (MoA) July 21 24 Ceramics #213 Ages 9-12 $ 60 to July 21 24 Mixed Media #214 Ages 5-8 $ 60 Participants create unique mixed media projects inspired by exhibits in the City s Museum System. (MoA) July 21 24 Ceramics #215 Ages 5-8 $ 60 to July 21 24 World Art Adventures #216 Ages 9-12 $ 60 Students will be creating mixed mead art work based on the art and cultures from all over the world. (MoA) July 21 24 Pet Portaits #217 Ages 9-12 $ 60 Learn the fundamental techniques of drawing and painting while creating a portrait of your fury friend. Photo of pet is required. (MoA) July 28 31 Ceramics #218 Ages 5-8 $ 60 to
Date of Program: Name of Workshop Program: Age Group: Cost: July 28 31 Nature Drawing #219 Ages 9-12 $ 60 Learn how to draw nature and the outdoors, with helpful tutorials to create beautiful illustrations and drawings. (MoA) July 28 31 Mixed Media #220 Ages 5-8 $ 60 Participants create unique mixed media projects inspired by exhibits in the City s Museum System. (MoA) July 28 31 Ceramics #221 Ages 9-12 $ 60 to July 28 31 Nature Drawing #222 Ages 5-8 $ 60 Learn how to draw nature and the outdoors, with helpful tutorials to create beautiful illustrations and drawings. (MoA) July 28 31 Mixed Media #223 Ages 9-12 $ 60 Participants create unique mixed media projects inspired by exhibits in the City s Museum System. (MoA) Please make checks payable to: City of Las Cruces Total Fee: Parent/Guardian Signature Date:
Las Cruces Museum System SUMMER PROGRAM STUDENT INFORMATION Student s Name Age Program Attending Address City State Zip Phone Grade (as of August) Birthdate Parent/ Guardian s Name Daytime phone Alt. phone Parent/ Guardian s Name Daytime phone Alt. phone Physician s Name Phone Insurance Provider Name of policyholder Policy number Emergency Contact Information Authorized Pick-up Person(s) (other than parent/guardian) (Only those listed will be allowed to sign out your child. Proper ID must be shown)
Las Cruces Museum Systems Medical Information Does your child have any of the following (check all that apply)? Seasonal allergies Medication allergies (please list below) Food Allergies (please list below) Asthma Epilepsy Diabetes Insect sting allergies (please explain below) Other (please explain below) Is your child on any medications? If yes, please list Will your child need to receive medication during the program day? Yes No If yes, please list name of medication, dosage, and time to administer: All medications must be in the original container and accompanied by a physician s note or they will not be administered. Does your child have any serious fears or phobias? If so, please explain: Does your child have any relevant physical limitations or handicaps? If so, please explain:
Las Cruces Museum Systems Parent Agreement (Please initial each statement) I give permission to the Las Cruces Museum System to administer emergency medical attention to my child in my absence. I understand the Las Cruces Museum System will make every effort to contact the parent in case of any emergency. I understand I am liable for any medical care costs incurred in the case of emergency treatment. The information above is correct and current to the best of my knowledge. I agree to make the Las Cruces Museum System aware of any changes to address, phone, emergency contact information, etc. as soon as these changes occur. I give my permission for my child to participate in all the field trips of the Las Cruces Museum System. I authorize the Las Cruces Museum System to use any photograph, video images, or slides of my child for public relations purposes. I do not want any pictures taken of my child. Behavior Contract (Please Initial) Any child exhibiting behavior that may cause harm to themselves, other students, or program staff will be asked to leave. These behaviors include, but are not limited to, hitting, kicking, biting, sexual harassment, and/or possessing weapons or illegal substances. I have discussed the above rules with my child and agree to abide by them. I understand that if my child does not follow these principles, they may be asked to leave the Summer Program. Refunds will not be given due to expulsion or suspension from program. Late Pick-up Policy Summer programs end each day at the specified time. Any child remaining after this time will be subject to a late fee of $5 per 15 minutes, payable at the time of pickup. If we are unable to contact a parent/guardian within 30 minutes, we will then contact the Department of Social Services Child Protection Agency. I,, agree to pay any late fees in accordance with the above policy. Name of Parent
Las Cruces Museum Systems STUDENT RELEASE AND WAIVER OF LIABILITY Summer Program The undersigned wishes to participate as a student in a City of Las Cruces Student Activity. In signing this agreement: A. The undersigned agrees to abide by all policies concerning the Student Activity that are provided or explained to the student. B. The undersigned recognizes that the Student Activity is not without risks. The undersigned agrees to help minimize those risks by exercising reasonable judgment and due care for his/her own safety. The undersigned also recognizes that he/she is a student and may choose not to perform a task requested by Summer Program personnel, especially if the request goes beyond the risks that the undersigned wishes to accept. C. The undersigned acknowledges he/she is not an employee of the City of Las Cruces and is therefore, not provided with workers' compensation coverage, salary, medical insurance or any other benefit available to employees of the City of Las Cruces. If a student is injured, suffers a loss or is sued as part of the student activity, he/she will have such rights, defenses and privileges as are granted by the New Mexico Tort Claims Actions, 41-4-1, et seq. NMSA 1978 (1996 Repl) and as amended. All students will be participating in all the field trips as scheduled in the Summer Program brochure unless specified in writing by Parent or Guardian. Due to safety considerations, all students must follow all rules of conduct and safety during Summer Programs. Failure to follow these rules may result in the student being dropped from the program. Permission/Consent: has my consent to participate in the Summer Program under supervision of instructors. I understand this program involves some risks and is purely voluntary in nature. I hereby release the City of Las Cruces and City staff or instructors from any claim for personal injury or property damage suffered by me or by my minor child as a result of participating in the above described day trip/overnight program. Name Phone Address In case of emergency contact: Signature of Student Date Signature of Parent: Date (Required for students under 18 years of age)
Las Cruces Museum Systems RELEASE AND SETTLEMENT OF CLAIM FOR DAMAGES Participant over 18 Date: Name of Participant,. The undersigned participant hereby releases THE CITY OF LAS CRUCES and its employees, agents and officials from all claims and demands, rights and causes of action of any kind resulting or to result from an occurrence which may occur and do hereby covenant to indemnify and hold harmless the said party or parties from and against all claims and demands whatsoever on account of or in any way growing out of said occurrence. Signature of Participant: Witness: Participant under 18 Date: Name of Participant,, has my permission to participate in any recreation program under the supervision of appointed personnel. The undersigned and participant hereby releases THE CITY OF LAS CRUCES and its employees, agents and officials from all claims and demands, rights and causes of action of any kind resulting or to result from an occurrence which may occur and do hereby covenant to indemnify and hold harmless the said party or parties from and against all claims and demands whatsoever on account of or in any way growing out of said occurrence. Signature of Parent or Legal Guardian: Witness: