Registration Form 1-6

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We are pleased to announce our annual Summer Art Camp for rising 1st-6th graders, organized by the Sampson Arts Council. The camp offers a variety of classes taught by professional instructors in different art topics such as painting, sculpture, drawing, and more. Classes will be held Monday through Thursday from 9:00 am to 12:00 pm. Please note that Summer Art Camp is limited to a total of 30 students. Parents are responsible for student transportation to and from the camp each day. To register for the Summer Art Camp, please complete the following form by June 10, 2024. If you have any questions, please contact us at 910-596-2533 or director@sampsonarts.org.

Parent/Guardian Submission

This form is to be completed by the Parent/Guardian of the student. If your student has been selected to receive a scholarship, it will not be awarded until this form has been submitted.

Student Name *

Student Age *

Grade Fall 2024

School Attending *

Student is a scholarship recipient *

Yes

Not Sure

Parent/Guardian Name *

Parent/Guardian Mailing Address *

Parent/Guardian Email *

Parent/Guardian Phone Number *

I give permission for my child's name/photo to be used in Sampson Arts Council's promotional materials. *

Yes, I give permission for my child's name and photo to be used in promotional materials.

No, I do not consent to my child's name or photo being used in promotional materials.

Emergency Care Information *

If the Parent/Guardian cannot be reached, please call the following contact in case of an emergency:

Emergency Care Information *

Contact Phone Number

Emergency Care Information

In case of emergency, permission is given for the director or teacher to determine whether a situation requires simple first aid or immediate transport to the nearest medical facility.

Student will be attending the following Summer Art Camp *

July 8 - July 11 - Victor R. Small House, 709 College St. in Clinton (9am-12am) (Pet Portraits & Sculptures)

July 22 - July 25 - Town Hall, 101 W Pleasant St. in Roseboro (9am-12am) (Mini Masters)

Please understand that if you answered 'No' to the previous statement 'Student is a scholarship recipient,' a payment of $100 (with membership) or $150 (without membership) will be due before June 10, 2024. You can make the payment with a credit card at http://weblink.donorperfect.com/sac2024. You can also pay with a check or cash in person. Please agree to one of the following before submitting this form.
*

I agree to make the payment of $100 (with membership) before June 10, 2024.

I agree to make the payment of $150 (without membership) before June 10, 2024.

I confirm that the student is a scholarship recipient and no payment is required before June 10, 2024.

Submit

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