Friends of Madison Youth/Madison Youth & Family Services

Madison Arts Barn Day Camp Registration Summer 2012

Name______Boy: ____ Girl:____ Age/Upcoming Grade______

Street Address:______D.O.B.:______

Town:______Zip:______Home Phone: ( )______

Family E-mail______

Father or Guardian:______Work Phone: ( )______

Cell Phone: ( )______

Mother or Guardian:______Work Phone: ( )______

Cell Phone: ( )______

Emergency Contact Person:______Phone: ( )______

Check / Date / Time / Program / Cost
June 25th – 29th / 8:30am – 3:30 pm /

Art Station Vacation

/ $250/week
July 9th-13th / 8:30am-3:30pm / Game Show Mania / $225/week
July 9th – 13th / 3:30pm – 6:30pm / Rock Band Live! / $175/week
Every Monday
July 9th – Aug 20th
(except Aug 6th) / 3:30 – 4:30 pm / Inspiring Wings – Yoga Workshop / $75/5 sessions
July 16th-20th / 8:30am-3:30pm / Survival Skills w/ Erik Becker / $250/week
July 23rd-27th / 8:30am-3:30pm / Center Stage Theatre Camp / $225/week
August 6th – 10th / 8:30am – 12:00pm / Art Exploration / $175/week
August 6th – 10th / 12:00 pm – 3:30pm / The Best of the Barn / $150/week
August 6th-10th / 8:30am-3:30pm / Art Exploration/The Best of the Barn - Combination / $250/week
August 13th-17th / 8:30am-3:30pm / The Famished Games / $250/week
August 20th-24th / 8:30am-3:30pm / Get Crafty Camp / $225/week
Every Wed/ July 18th – Aug. 22nd / 4:00 pm – 6:00 pm /

Cartooning Workshop

/ $200/6 sessions
Every Thurs/July 19th – Aug. 23rd / 4:00pm-6:00pm / The Art of Graffiti Workshop / $225/6 sessions
June 25th – 29th / 3:30pm – 5:30pm / After Camp and Beyond / $50/week
July 9th-13th / 3:30pm-5:30pm / After Camp and Beyond / $50/week
July 16th-20th / 3:30pm-5:30pm / After Camp and Beyond / $50/week
July 23rd-27th / 3:30pm-5:30pm / After Camp and Beyond / $50/week
July 30th – August 3rd / 3:30pm-5:30pm / After Camp and Beyond / $50/week
August 6th – 10th / 3:30pm – 5:30 pm / After Camp and Beyond / $50/week
August 20th – 24th / 3:30pm – 5:30pm / After Camp and Beyond / $50/week
August 13th-17th / 3:30pm-5:30pm / After Camp and Beyond / $50/week
August 5th / 2:00pm – 5:00pm / College Application & Resume Building Workshop / $45/Workshop
August 12th / 2:00pm – 5:00pm / College Appication & Resume Building Workshop / $45/workshop
Math Tutoring / $35/session
Language Arts Tutoring / $35/session
Skateboard Lessons / $30/Hour

This application has my consent. I authorize the Camp Director to act for me according to his/her best judgment in any emergency, and in the event that I cannot be reached, I hereby give permission to the selected physician to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child. My child has permission to take part in all organized and supervised activities. The camp, for publicity purposes, may use photographs and videos in which my child appears. I understand that the Madison Arts Barn Day Camp will not accommodate campers with severe behavioral problems. Campers with frequent violent or uncontrollable outbursts, an unwillingness to respond to supervision or behavior that infringes upon the camp experience of others will be asked to leave our program without a refund.

Payment in full is due at time of registration. Payment can be made at the Madison Arts Barn during open hours (Monday evenings 6:30 PM to 8:30 PM or Tuesday and Thursday afternoons 3:30 PM – 5:30 PM), online at www.themadisonartsbarn.org (under the buy event tickets tab) or mailed to The Madison Arts Barn, P.O. Box 54, Madison, CT 06443. Make checks payable to FOMY. Registration requires this fully completed registration form and the Health Exam/ Record and authorization for the self-administration of Medication Forms. Financial assistance and scholarships may be available by contacting Wendy Larson at Madison Youth and Family Services at 203-245-5655 or contacting Friends of Madison Youth at 203-245-2689. A 10% discount of the third and all subsequent weeks will be given to anyone registering for three or more camp weeks for the 2012 summer session. A 5% sibling discount will be given for each sibling registering for the same summer camp week. Discounts are not available with online payments, please pay at the Barn or though the mail. Credit vouchers for future Arts Barn events will be given for any day missed with a doctor’s note.

Signature of parent or guardian______Date______