3201 South 17th Street | Wilmington, NC 28412 | 910-395-5999
cameronartmuseum.com
Kids@Camp and Summer Museum School Children’s Class
Scholarship Request Form
*CAM staff, their family members or CAM volunteers are not eligible for Scholarship funds*
Registration and Contact Information
All information must be completed and signed by parent or guardian
in order for a child to be considered for a scholarship.
Kids @ CAMP session or Museum School Class name _______
Class or Camp Dates & Times:______
Name: _______Age:______
Grade :______Birth Date: ______M/F:______
Parent/ Guardian’s Name:______
Address:______
City:______State:______Zip:______
Daytime Phone:______Evening Phone:______
Cell Phone:______Email:______
Emergency Contact other than above parent/guardian: ______
Contact’s relationship to child:______Phone:______
Who is authorized to pick up your child?
Name:______Relationship to child:______
Name:______Relationship to child:______
Please list any medical problems, special needs or concerns that the museum staff needs to be aware of: ______
Who informed you about this scholarship opportunity?:______
Waiver of Liability: I hereby release the Cameron Art Museum, its employees, volunteers, and board members from any and all liability, cost or expense associated with an injury I/my child may sustain while participating in “After-School Art Classes.” I further authorize the Cameron Art Museum representatives to make necessary emergency medical decisions that are felt to be in the best interest of my child should I be unavailable.
Notice: Photos are often taken on the premises during classes and special programs to capture images for use in publicity materials, grants and our website.
__I authorize having my/child’s photo taken. __I do not authorize having my/child’s photo taken.
Parent/Guardian Signature:______Date:______
Parent Contact/Transportation/Attendance Agreement (Required)
· I agree to keep the museum informed of any changes to my phone number so that they will be able to reach me in the event of an emergency.
· I agree that it is my responsibility to provide transportation for my child to be dropped off and be picked up at the designated times for this class.
· A agree to notify the Museum if my child will not be able to attend any class for any reason by calling and 910-395-5999 Ex. 1008.
· I agree that if my child does not arrive on time for the first day of class, their scholarship will be forfeited, and the scholarship will be given to a child on the waiting list. Further, I understand that my child will not be able to apply for another scholarship during the summer of 2016 if a scholarship is forfeited.
______
Parent or Guardian Name (printed) Parent or Guardian Signature Date
Scholarship Essay – To be completed by child and parent together
Please tell us why you would like to attend this camp and what you hope to gain from the experience.
______
______
Scholarship App 03.2016