Middle School Art Extravaganza Summer Enrichment Program 2021 Registration Form

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Students will be provided materials for the course as needed.

Come create various art projects from glazing clay plates, painting on canvas, making lanyards, to painting pillowcases! Have some fun and begin to express yourself more through art. This is an opportunity to explore your creativity with the direction of a seasoned art teacher from Monroe.
Let’s create together!

**The Summer art program will be held in accordance with 4J School District COVID safety protocols specific to music education. Including the practice of social distancing and required PPE.**]

Teacher: Claire Kronser kronser@4j.lane.edu
Dates: August 2 -6
Times: 9am until noon

Location: Monroe Middle School Art Room
Grades: Middle School grades 6 - 8
Prerequisites: No experience needed just a love for art

Email *

Student's LAST Name *

Student's FIRST Name

Student's 4J Identification Number

Middle School Student Will Be Attending in FA2021: *

Arts and Technology Academy

Cal Young Middle School

Kelly Middle School

Kennedy Middle School

Eugene Online Academy

Madison Middle School

Monroe Middle School

Roosevelt Middle School

Spencer Butte Middle School

Other:

Student Home Address: *

Example: 200 N Monroe St., Eugene, OR 97402

Parent / Guardian Last Name: *

Parent / Guardian First Name: *

Parent/Guardian Phone Numbers - Cell, Home, Work *

Please list all available numbers. Examples: 541-790-7700 (Cell) 541-790-7701 (Home) 541-790-7702 (Work)

Name of Emergency Contact : *

Emergency Contact Relationship: *

Example: Grandmother, Aunt, Family Friend, etc.

Emergency Contact Phone *

Example: 541-790-7700

Health Conditions: Please indicate if any of these or other conditions apply to your child.

Asthma (please list more specific information below)

Diabetes (please list more specific information below)

Heart Condition (please list more specific information below)

Hearing Loss (please list more specific information below)

Orthopedic Condition (please list more specific information below)

Mobility Limitation (please list more specific information below)

Severe Bee Sting (please list more specific information below)

Seizures (please list more specific information below)

Severe Food Allergy (list which food or foods below)

Speech Disorder (please list more specific information in prompt below)

Other Allergies (please list more specific information in prompt below)

Other:

Please indicate if your student is supported by

IEP

504

As appropriate, please provide more specific information on health conditions, including required accommodations.

If the student requires prescription medication while attending this Summer Intensive Course, please list.

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