Mural Mania! IV July 19- August 13, 2021 Summer Arts Enrichment Camp Registration

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A 4-WEEK SUMMER MURAL ARTS PROGRAM FOR BUFFALO PUBLIC SCHOOLS STUDENTS ENTERING GRADES 7-12 STARTING SEPTEMBER 2021.

PROGRAM SITE: Dr. Antonia Pantoja Community School of Excellence #18, 750 West Ave., Buffalo, NY 14213

MURAL LOCATION SITE: Broderick Park, 1170 Niagara Street, Buffalo, NY 14213

There is space for 20 student artists. All students must commit to 4 weeks of the program. Students will be chosen by lottery.

Breakfast and lunch will be available to all participating students.

Confirmation of your registration will be emailed to primary contact by June 21, 2021.

This is an online registration form. You will receive a confirmation email once it is submitted.

IF YOU NEED TO PRINT THIS FORM, PLEASE DIRECT YOUR REGISTRATION APPLICATION TO:
Michele Agosto, Director of Arts or Audrey King, Arts Administrative Assistant
EMAIL: magosto@buffaloschools.org OR aking@buffaloschools.org

Email *

First Name of Student *

Last Name of Student *

School *

Grade *

Age *

Student Artist's Gender Identity *

he/his

she/her

they/their

Prefer not to say

Other:

Student Cell Phone *

#1 Parent Name/Guardian (PRIMARY CONTACT) *

Home Phone Number #1 Parent/Guardian (PRIMARY CONTACT) *

Cell Phone Number #1 Parent/Guardian (PRIMARY CONTACT) *

#2 Parent/Guardian Name (SECONDARY CONTACT) *

Home Phone Number #2 Parent/Guardian (SECONDARY CONTACT) *

Cell Phone Number #2 Parent/Guardian (SECONDARY CONTACT) *

Student Artist's Home Address *

Primary Email Address (confirmation will be sent to this email address) *

Any Allergies or Medical Conditions? Please list all. *

Do you agree to allow your child to be photographed and videotaped as part of the marketing of this program? *

Yes

Any additional comments

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

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