2026 Summer Art Camp (Kindergarten -12 years old) Registration Form

2026 Summer Art Camp 5-12 years old (Kindergarten- 12 years old) June 15-19 Cost is $300 per child.

9:00 am-12:00 pm
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number
E-mail*
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the student have any medical or allergy conditions?
Adults authorized to pick up or drop off my child. Please Include their phone number.*
Is the student prescribed an inhaler? If yes, please explain any instructions.
I give Permission for my child's picture to be used on the Dallimonti Pottery Website*

YesNo
Informed Consent and Acknowledgement: I hereby give my approval for my child’s participation in any and all activities prepared during the selected camp. In exchange for the acceptance of said child’s candidacy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Dallimonti Pottery, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.In case of injury to said child, I hereby waive all claims against Dallimonti Pottery, including all volunteers, helpers, affiliates, all participants, and, if applicable, owners and lessors of premises used to conduct the event. *
Medical Release and Authorization: As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.Permission is also granted to Dallimonti Pottery, and its affiliates including leaders, and Team helpers to provide the needed emergency treatment prior to the child’s admission to the medical facility.Release authorized on the dates and/or duration of the registered session. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.*

I agree
Confirmation: BY ACKNOWLEDGING AND SUBMITTING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.*

YESNO
By Submitting this form, I agree to the informed consent and Medical Release Statements on this application*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

2026 Summer Art Camp 5-12 years old (Kindergarten- 12 years old) June 15-19 Cost is $300 per child.