Emergency Contact Information

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Please complete this form with emergency contact information for children you are registering for Garrison Art Center programs. If you are registering more than two children for our programs, please fill out an additional form as needed.

Email *

Parent Name *

First and last name

Phone number *

Student Name #1 *

First and last name

Grade in School *

Date of birth *

YYYY

Student Name #2

First and last name

Grade in School

Date of birth

YYYY

Parent/Guardian phone number *

Street Address *

City, ST, Zip *

Alternate Emergency Contact (name) *

Alternate Emergency Contact (phone) *

Child's Physician (name) *

Child's Physician (phone) *

Garrison Art Center occasionally photographs and records aspects of the summer program for promotional or grant-related purposes. We never use a child’s name or personal details. If you are opposed to the use of images with your child’s face in it, please check here:

I do not authorize the use of images of my child’s likeness for promotional purposes by Garrison Art Center.

A copy of your responses will be emailed to the address you provided.

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