RILA Summer Art Camp Registration Form

Summer Camp Application

Rhode Island Latino Arts | Summer camp for Latino/Latina youth
Name of student/Nombre*

First NameMiddle InitialLast Name
Name of School and Grade*
This art camp is primarily for students ages 13-16
Yes
Date of Birth/Nacimiento*

MonthDayYear
Date
Female/HembraMale/VarónPrefer not to answer/prefiero no contestar
Preferred Pronouns/Pronombres Preferidos
Email*
example@example.com
Mobile Phone/Celular*
Format: (000) 000-0000.
Home Address/Dirección*

Street Address

Street Address Line 2

City/State/Zip CodeState / Province

Postal / Zip Code
Bilingual Visual Art Camp (Tues-Wed-Thu) July 15-31
Medical Information / Información Médica
Does the student have allergies including asthma?/¿Tiene el estudiante alergias, incluido asma?*
Please explain including which food the camper is allergic / Por favor explique incluyendo cualquier alimento al que el estudiante sea alérgico.
Is the student currently under medication/¿Está el estudiante actualmente bajo medicación? *
Please provide the details, the name of the medication and period of intake / Proporcione los detalles, el nombre del medicamento y el período de ingesta.
Contact Information in Case of Emergency / Información de contacto en caso de emergencia
Name/Nombre*

First NameLast Name
Contact Number/Número telefónico*
Format: (000) 000-0000.
Relation to camper/Relación con el /la estudiante*
Parent or Guardian Signature/Firma de Padre*

Clear
Payment/Pago
The amount that appears below is the total amount payable to the camp. You may submit your payment on the first day of the camp session.
Total amount

I would like to pay / me gustaría pagar (Include Scholarship Amount if applicable / Escriba el monto de beca si corresponde)

Visual Art Bilingual Summer Camp (4 weeks)

July 15-31 (T-W-Th)

$500.00 4-weeks
Item subtotal:$0.00

Enter coupon

Total

$0.00

Should be Empty:

Summer Camp Application

Medical Information / Información Médica

Contact Information in Case of Emergency / Información de contacto en caso de emergencia

Payment/Pago