The Irma Freeman Center For Imagination

Registration Form for Classes & Workshops

This form and the Emergency Medical Release form MUST

BE COMPLETED in their entirety in order for you or your child to

be registered for IF Center Classes or Workshops.

Participant’s Name___________________________________Female: ___Male: __

If Under 18:  Birth date: ___________  Age during camp, class or workshop: ____ 

Grade child will enter in the Fall:___________________

Name; Parent or Guardian Name (primary contact): _______________________________________________

Address:  ___________________________________ City:  _________________ Zip:  _______

Daytime Phone:  _______________ Home Phone:  _________________

Cell Phone: _______________

Fax: ____________________ E-mail address: ______________________________

Secondary contact:  _____________________________________________

Address:  ___________________________________ City:  _________________ Zip:  _______

Daytime Phone:  _______________ Home Phone:  _________________

Cell Phone: ________________

Fax: _____________________E-mail address: ______________________________________

CLASS & WORKSHOP SESSIONS : please list

1.                                                                                       

      2.                                                                                       

      3.                                                                                       

PLEASE NOTE:

In the event we are not able to accommodate your first request, we will try to place your child into a second choice or third choice

How did you hear about this program?        

Payment Information

O  Check here if Payment Information below is for multiple children (registration forms attached).

Please check class listing for total price including class fee

TOTAL ENCLOSED ________

O I have enclosed a check payable to the Irma Freeman Center for Imagination

O I have paid in cash & received a receipt of payment

O I want to apply for a scholarship based on financial need

Name______________________________________________________

Mailing Address ________________________________________________________________

Signature________________________________________________________

Waiver/Release of Claims

PHOTO RELEASE:  I give the Irma Freeman Center for Imagination permission to publish in print, electronic or video format the likeness or image of my child/children.  I release all claims against the Irma Freeman Center for Imagination with respect to copyright ownership and publication including any claim for compensation related to use of the materials.  I understand cautionary steps will be taken to provide minimum identifying information and no specific mailing address or phone number will be used.

O   I AGREE                   O   I DISAGREE  

RELEASE OF CLAIMS:   As part of the consideration tendered for my child/children being permitted to participate in Summer Day, Classes or Workshops at the Irma Freeman Center for Imagination activities, I agree to and do hereby waive any and all claims against, and agree to fully release, hold harmless, and indemnify, the Irma Freeman Center for Imagination, its officers, employees, agents, and volunteers from any and all claims related to any illness, injury, including loss of life, property damage, or loss of any other description which my child/children may sustain arising out of, or in any way associated with, my child’s/children’s participation in Classes, or Workshop activities.

Signature of Parent/Guardian:  _______________________________  

Date:  __________

Signature of Executive Director:  _______________________________  

Date:  __________

CANCELLATION & CHANGE POLICY 

If you must cancel your registration you will be eligible for a full refund (minus a $25 processing fee) if the cancellation is made at least 2 weeks before the camp starting date.  Cancellations received with less than 2 weeks' notice will not be eligible for any refund unless a replacement is available to take you or your child’s spot. If you would like to reschedule your class, a $25 processing fee will be charged and changes will be accommodated only when there is space available.

I have read and agree to abide by the cancellation and image release policies. 

X

Signature of parent or guardian Date

IRMA FREEMAN SCHOLARSHIP FUND PROGRAM

Scholarships are available for low-income families and will be awarded on the basis of need and availability.  Please indicate how much of the normal camp fee you can afford:  $____________

If you think you may qualify, please ask for the Irma Freeman Scholarship Fund Application.  To receive a scholarship application, please send you name and mailing address with a written request for the application form by writing to calling with your mailing information to:

Sheila Ali, Executive Director, Irma Freeman Center for Imagination, or obtain a copy on our website www.irmafreeman.com Write to 5006 Penn Avenue, Pittsburgh, PA 15224 or calling 412-924-0634 at the IF Center. You may also email Sheila Ali, Executive Director at sheiladali@yahoo.com

Scholarships are based on financial need and are distributed on a first come first serve basis.

                                                   

MEDICAL RELEASE INFORMATION

Participant’s or Child's Name:  ________________________________________________________________________

Primary emergency contact name:  ________________________________________________________

Daytime phone number:  _____________________________Relationship:  _______________

Secondary emergency contact name:  ______________________________________________________

Daytime phone number:  _____________________________Relationship:  _______________

Doctor’s Name: _________________________Doctor’s Phone Number: _________________

Medical Insurance______________________  Policy # _______________________________

If a participant do you or your child have any allergies, medical conditions or special needs that it would be helpful for us to know about?  Please specify what your child is allergic to and what reaction is typical.  It is especially important that we learn about allergies to bee stings and foods.  __________________________________________________________________________

Will your child be taking any medication while at the Irma Freeman Center for Imagination? 

If so, please detail:

____________________________________________________________________________

(Any medication your child will be bringing to class should be in a ziplock bag clearly labeled with his or her name.)

In the event of an emergency, if we cannot reach you, please indicate your permission to authorize emergency care by signing below:

X

Signature of participant  (over 18), parent or guardian Date