Summer Workshop Registration Form

Welcome to the 2018 Pequot Library Youth Summer Programs!

We’re excited that you have decided to join us for one or more sessions this summer. If you have any additional questions after reading this information, please feel to contact us at (203) 259-0346 ext. 16.

Important Phone Numbers:

Circulation Desk (For general information): (203) 259-0346 ext. 15
Public Programs Manager, Tracy Steneken: (203) 259-0346 ext. 19

Participant
Name of Participant*
First Last
Date of Birth*
Month
Day
Year
Grade*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number*
Parent/Guardians
Parent/Guardian #1*
First Last
Address (If different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Work Phone*
Cell Phone*
Parent/Guardian #2*
First Last
Work Phone*
Cell Phone*
Emergency Contact
Emergency Contact*
First Last
Relationship*
Phone Number*
Cell Phone*
Health Information
Dr.'s Name*
First Last
Phone Number*
Allergies/Medications/Special Considerations*
I hereby give permission for emergency medical treatment which will include but not be limited to initial diagnostic x-rays and other such procedures as the physician may deem necessary for the preservation of health. I agree to assume all costs related to such treatment. I hereby waive and release Pequot Library directors, staff, teachers and volunteers from and against all claims and medical and legal costs associated from my child’s/children’s program participation.
Pick-Up Consent
I give permission for the parent/guardian listed above as well as the following people to pick up my child from Pequot Library’s Summer Program. I understand that my child will not be released to any individual not listed on this form.
Name*
First Last
Relationship*
Phone Number*
Name*
First Last
Relationship*
Phone Number*
Photographic and Internet Release
I...*
- do
- do not
…give permission for my child to be photographed, videotaped. I understand that any pictures may be used in literature advertising the programming or activities at Pequot Library. I also understand that children who are enrolled in certain classes must have a signed release in order to participate in these programs.
Parent's Full Name*
First Last
Parent's Signature*
First Last
By signing this form, you acknowledge the following: I understand that anyone in my party may be photographed and that imagery may be used for publicity purposes for Pequot Library programs.
Date*
Month
Day
Year

Important Information

Drop Off/Sign In

Workshops begin at 9:00am. All participants sign in at the Circulation Desk. They must be accompanied by a parent or guardian over the age of 18. Sign in will begin promptly at 9:00 am. Unfortunately, we cannot accommodate early drop-offs.

Snacks

Our program allows time for snacks, so each participant should bring one snack for every session. Due to allergy concerns, no peanut or tree nut products or items are allowed.

Pick Up

All children must be signed out by a parent or an adult who is listed on the contact sheet. Changes made over the phone will not be accepted. Students are not permitted to leave the Library interior until the adult arrives and cannot be picked up from the parking area. Early Dismissals – If it becomes necessary for your child to be dismissed early, please inform the staff at the Circulation Desk, and a staff member will deliver the student to the reception area. Late Pick-Ups – Please contact the Circulation Desk of the Library if you are unavoidably delayed by calling (203) 259-0346 ext. 15.

Refunds

Cancellations made prior to May 15 are available minus a $25 processing charge. All classes must have a minimum number of children registered in order to be offered. In case of cancellation, you will be notified by May 30 and a full refund is available.

What to Bring

WaterBottles
Peanut/Tree Nut-Free Snack

What Not to Bring

Cell Phones may be carried, but are not to be used during the program
Hand-held Electronics(iPods,Video Games, etc.)
Personal toys/games
DUE TO ALLERGY CONCERNS, ITEMS CONTAINING TREE NUTS, PEANUTS AND ITEMS PROCESSED IN A PEANUT/TREE NUT FACILITY ARE NOT ALLOWED.

Pequot Library is not responsible for the loss of or damage to any items participants choose to bring from home.

Behavior Contract

A behavior contract must be reviewed and signed by the parent/guardian of each participant in the program. A child cannot start the program without a signed behavior contract. Submit the form here.

Dress Code

We ask that children wear comfortable clothing. Please remember that children may be indoors as well as outside each day (weather permitting). Being a young artist can be messy. Dress your child in clothing that can get dirty or bring a smock.

Summer Workshop Registration Form

Welcome to the 2018 Pequot Library Youth Summer Programs!

Participant

Parent/Guardians

Emergency Contact

Health Information

Pick-Up Consent

Photographic and Internet Release