Middle School Teen Art Program School Year 2023-24

Middle School Teen Art Program Registration Form

This form is for youth that are enrolled in middle school or of middle school enrollment age during the September 2023 - June 2024 school year.
Use this form to sign up for Push/Pull's free Teen Art Program on Wednesdays 3:30pm - 5pm. Classes will start September 27th. There will be no classes during school breaks (Seattle District).

All materials and tools are provided. Individually wrapped snacks and drinks are provided. Proof of vaccination (and applicable boosters) must be provided (upload image below) and students are encouraged and may be required to wear masks, which can be provided.
Please have students complete this top portion:
Yes
Yes
Start Date*

MonthDayYear
Date
Student info
Teen Name*

First NameLast Name
Pronouns*
Birthdate:*

MonthDayYear
Date
Student Email*
example@example.com
Student Phone Number*

Area CodePhone Number
Describe your art experience and any projects you are working on:
Acrylic paintWatercolor paintMarkers/PensGraphiteCharcoalOther
Acrylic paintWatercolor paintMarkers/PensGraphiteGouacheOther
School you attend *
Please list any allergies or medical conditions:
Please list anything our teachers should know about your learning needs:
Guardian/Student Info

Please have a guardian complete this section:
Parent/Guardian Contact

First NameLast Name
Relationship to student
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Secondary Contact

First NameLast Name
Relationship to student:
Email
example@example.com
Phone Number

Area CodePhone Number
Student Data

The below info is optional but will help us to track who we are reaching and is useful for grants and other fundraising.
Latinx / HispanicWhite / CaucasianNative American / IndigenousAsianPacific IslanderBlack / African AmericanOther
YesNoNot SureOther
YesNoOther
YesNoOther
under $30,000$30,000 - $45,000$46,000 - $55,000$56,000 - $70,000$70,000 - $85,0000Over $85,000
Number of Family Members at Primary Home
Push/Pull is located at 2000 NW Market St in Ballard. We have fluorescent lights and our bathroom is not ADA accessible. If you are concerned about either of these obstacles or have other accessibility concerns, please contact info@pushpullseattle.com before enrolling.
There is an element of risk inherent in participating in the artistic process, handling materials and using tools. Push/Pull takes every precaution to ensure the safety of our facility users. It is important that all students follow safety instructions from their teachers. The following general waiver must be signed in order to participate in any educational program at Push/Pull.

Consent to hold harmless:

In consideration of my participation in the educational program(s), I hereby discharge and forever hold harmless Push/Pull, its Board members, staff and volunteers, and all agencies whose property and personnel are used as part of Push/Pull's educational program and any sponsoring, co-sponsoring or funding agency(ies) or individual(s) for responsibility for any injury, illness, death, damage, loss, accident, delay or irregularity which may be occasioned for any reason whatsoever during the course of my participation. I certify that the participant named herein is physically able to participate in all activities for which they are enrolled. Push/Pull assumes no responsibility for losses or additional expenses due to influences beyond its control.

Consent for documentation:

I consent for Push/Pull to use without limitation or obligation: photographs, film footage, tape or video recordings which may include the student's image, voice and/or artwork created though the program.

Consent for emergency treatment:

I hereby give permission for my child to be given emergency treatment by a qualified member of Push/Pull. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. In the event that I cannot be contacted, I further consent to the medical, surgical and hospital care, treatment and procedures to be performed for my child by a licenses physician or hospital when deemed immediately necessary or advisable by the physician to safeguard my child's health. I certify that my child is covered by medical insurance for the duration of the program. If my child arrives ill or becomes ill during the program, I understand they will be required to be removed from the program by myself of a person as noted above. The members of Push/Pull will not and cannot administer any drugs to my child.
I agree and have read all the terms and conditions above.
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Upload an image of student's vaccination card:
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Middle School Teen Art Program Registration Form

Student info

Guardian/Student Info

Student Data