Complete, sign & return with a check or cash Payable to:

Avigayle Adler 2/15 Ben Tabai, Jerusalem

The Open Studio Traveling Arts Camp ~ Summer 2014 ~ Registration Form For more than two children, please use an additional form Please indicate Session(s) and circle days (for daily registrants only). Price per session is 750/700 NIS (multiple sessions/siblings) unless indicated below. Daily price is 185 NIS. If different children are coming on different days or sessions, please indicate.

□ Session 1: July 1-10 Dig It! Archaeology Camp (1200/1120 NIS) Tu W Th S M □ Session 2: July 13-17 Paper Arts S M T W R □ Session 3: July 20-24 Monster Camp S M T W R □ Session 3: July 20-24 Painting & Drawing with the Masters S M T W R □ Session 4: July 27-31 Mosaics S M T W R □ Session 5: Aug 3, 4, 6, 7 Textile & Wearable Arts (600/560 NIS) S M W R □ □ Session 6: August 10-14 Paper Arts S M T W R □ □ Session 7: Aug 17-21 Textile/Wearable Arts & Mosaics S M T W R □ □ Session 8: August 24-28 Best of The Open Studio (750/700 NIS) S M T W R Child 1 First name: Last name: Entering grade: Teudat Zehut or US Passport #: Any known medical conditions, medications, allergies, etc: Special requests/dietary considerations/needs: Child 2 First name: Last name: Entering grade: Teudat Zehut or US Passport #: Any known medical conditions, medications, allergies, etc: Special requests/dietary considerations/needs:

Tu W T

□ Early Drop-off from 8:15am (80 NIS per week) □ Afternoon Program 2:15-4pm (200 NIS per week) □ Early Drop-Off AND Afternoon Program (8:15-4pm) (250 NIS per week)

Date of birth:

Gender: M/F

T-shirt size: ____

Date of birth:

Gender: M/F

T-shirt size: ____

Family Health Insurance Carrier: Family Doctor: Please indicate child # (above) and check any relevant boxes and fill in details below. Child #

Details:

Heart condition/murmur Asthma Diabetes Cancer Seizures

Child #

Kidney disease/injury Surgery Fractures Allergies Depression

Child #

ADD/ADHD Hearing problems Vision problems Chicken pox Measles, Mumps Rheumatic fever

Allergies: Food Allergies (peanuts, etc.): Environmental allergies (pollen, grass, cats, etc.): Insect Allergies (bee stings, etc.): Reaction: Epi Pen? Y N List any medications your child/ren currently take: Child 1 _________________________________________ When? _______________________ Child 2 __________________________________________ When? _______________________ Does any condition limit your child’s ability to participate in physical activities? Travel/walking, etc? Please explain: Y N Note: The Open Studio is not responsible from any injuries arising from accidents that occur through no fault or negligence on the part of The Open Studio. Address: Mailing address (if different): Email: Emergency Contacts Please indicate which adult should be contacted first, second and third in the case of an emergency: Adult 1: _______________________ Relationship: ___________________ Phone: ______________ Adult 2: _______________________ Relationship: ___________________ Phone: ______________ Adult 3: _______________________ Relationship: ___________________ Phone: ______________ Home Phone #1 _______________________ Home Phone #2 _______________________ My child/ren (check appropriate) ___ Speak only Hebrew ___ Speak only English ___ Speak/understand both English & Hebrew

___ Read & write only in Hebrew ___ Read & write only in English ___ Read & Write both English & Hebrew

Please initial 1. I give permission for my child/ren to participate in The Open Studio Traveling Arts Camps. ______ 2. I give permission for emergency medical treatment to be administered to my child in the event of a medical emergency, when neither parent can be reached. ______ 3. I understand that parents are responsible for the costs associated with medical services and for emergency transportation of my child. ______ 4. I have read and understand the attached Policies and Important Information. ______ 5. I give permission for pictures of my child to be used in print and online publications. ______ Parent’s Name: _____________________

Parent’s Signature: ____________________ Date _______

For office use only: sblng:___ early bird: ____ amt due:______ pd: ___________________

Traveling Arts Camp ~ Summer 2014 Policies and Important Information     

Payment is due at the time of registration to secure your child’s space in the program. Early Bird Discount (75 NIS off registration costs) will apply provided that payment arrangements are made by Sunday June 1, 2014. Checks should be made out to “Avigayle Adler”. If mailing, send to: 2/15 Ben Tabai, Jerusalem Guests (siblings, friends, etc.) of appropriate ages are welcome to join your child in camp at the rate of 185 nis per day. (based on availability) Refund Policy: up to 3 weeks before the start of camp – 80% refund, 2 weeks before 50%, after which, no refunds will be issued.

We will meet each morning at The Open Studio (2/15 Ben Tabai in San Simone) at 9:00am. If you are going to be late, please call Avigayle at 054-626-8496. Arrivals after 9:30am may be requested to meet us at an alternate location (if it is a trip day). Children will be given a healthy light snack at approximately 10:30 am, so please be sure to list any food allergies on their health form. This does not replace breakfast, so please make sure your child eats before coming to camp each morning. Please make sure that your child shows up for Camp each day with the following items:  Weather appropriate clothing that can get painted, stained, etc. We work with various types of paints and dyes, which are not washable. The Open Studio is not responsible for damage to clothing or personal belongings.  Comfortable Walking Shoes – Some of our site visits will include walking short distances. For the safety of your children, flip-flops will not be permitted.  Water Bottle & hat – minimum 1 liter of water required for each day of camp  Bag Lunch – Dairy or Pareve  Sketch Book – Weekly camp participants will be given a sketch book to bring and use each day of camp. Please make sure that your child has this each day. Replacement and additional sketch books can be purchased from the Open Studio for 20nis. Artwork that has not had sufficient time to dry by the end of camp can be picked up from the Open Studio one week after the end of each Session. Artwork left over 30 days will be discarded. Questions - Please contact Avigayle Adler at 054.626.8496 or email: [email protected]

www.openstudiojlem.com