Name of Purchaser/Parent *

First Name

Last Name

Class Date *

MM

DD

YYYY

Name of Child *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Alternative Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Mailing Address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone *

(###)

###

####

Emergency Contact Alt Phone

(###)

###

####

Second Parent/Guardian

First Name

Last Name

Phone

(###)

###

####

Alt Phone

(###)

###

####

Child's Physician Name:

First Name

Last Name

Child's Physician Phone Number

(###)

###

####

Parent/Guardian *

First Name

Last Name

Parent/Guardian

First Name

Last Name

Alternate:

First Name

Last Name

Field Trip Permission

My child has permission to participate in off-site activities. Transportation is exclusively limited to walking.

Yes

No

Photo Authorization *

I give permission to the Penticton Art Gallery to photograph my child for program promotional purposes. I understand that these images become the property of the Penticton Art Gallery and my child will be unidentified if the resulting photos are used in brochures, literature, or the website.

Yes

No

Emergency Authorization and Child Protection Policy *

Emergency Authorization The Penticton Art Gallery and its staff have permission in an emergency to call 911, and/or send my child to a Hospital/Medical Centre, and the Medical Personnel have my authorization to provide the treatment deemed necessary for the well-being of my child. The Penticton Art Gallery will make every reasonable attempt to contact the Parent/Guardian/Emergency Contacts. Child Protection Policy The Penticton Art Gallery commits to child safe practices and provides that any child or youth participating in any activity offered through the gallery has the right to be free from physical, emotional or sexual abuse when in contact with any PAG employee, contractor or volunteer. Authorization I have read, and agree to, the Penticton Art Gallery Registration Policies.

Yes