Student InformationStudent's Name* First Last Student's Age*Special Instruction? Allergies, medication, medical conditions, etc.Student's Physical Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent / Guardian InformationName First Last Cell Phone (No ability to text)*Home PhoneWork PhoneEmail* Important notifications will be sent via email!Class InformationType of Student*New StudentReturning StudentAre you an ACA Member?NoYesThere is a $25 discount per class if your an art angel member or higher. Would you like to become an ACA Member? Yes, please contact me about becoming a member Please choose the sessions you would like to attend. Session 1 June 4 – 7, 2019 Session 3 June 18 – 21, 2019 Session 4 June 25 – 28, 2019 Session 5 July 9 – 12, 2019 Session 6 July 16 – 19, 2019 Session 7 July 23 – 26, 2019 (Ages 13 to 17 only) All sessions are $105 for ACA Members, $130 Non-Members. Classes run from 9AM - 2PM.Total Number of SessionsFinancial AidScholarship requests are for internal ACA use only and are held in the strictest confidence. You will be contacted by email or phone with confirmation of your scholarship status. Financial aid awards are need-based scholarships, made possible by generous donations from the ACA Volunteer League, The Rotary Club of NSB, Gallery Patrons, ACA Members, and Individual supporters of Art Education.Reason for Scholarship Request Multiple Dependents Attending Attending Multiple Classes Financial Need Please check all that apply. Other reason for scholarship How many children are you planning to send to camp?For how many children are you requesting scholarship(s)?Release Form: Through this electronic registration submission, the Parent or Guardian accepts the ACA Summer Art Camp policies listed below, and will be required to sign a hard copy of the release form on the first day of Summer Camp. Full tuition is non-refundable once a space has been reserved unless requested at least one week prior to session. When possible, classes, scheduling and instructors will be as represented. They are subject to change without notice. I grant full permission to use photographs, video, and any other recordings of classes or the program involving me or my child(ren) for any legitimate purposes. In consideration of ACA’s acceptance of this enrollment, I hereby waive and release any and all rights and claims against Atlantic Center for the Arts. By signing this form, I acknowledge that I have read and understand the above policies. This agreement is a legally binding instrument when signed by registrant and accepted by Atlantic Center for the Arts. Thank you for choosing Atlantic Center for the Arts for Summer Art Camp! Serving our Community’s youth for over 23 years!