Participant Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Parent/Guardian *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Phone *

(###)

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If Yes, what is the name and contact information of additional person responsible for participant transportation?

First Name

Last Name

Phone

(###)

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Pick-Up/Drop-off schedule and locations *

M, T, Th, F: 8:30 AM drop-off, 1:00 PM pick-up at St. John's Episcopal Church, 48 Middle Street, Gloucester. (Parking available in church side parking lot at 38 Washington St.) Wednesday - QUARRY EXCURSION Pick- up and drop-off and Transportation arrangements TBD

Yes, I understand the Pick-Up/Drop-off schedule and locations

TUITION *

$175 per child; $125 per each additional child in the household (included in tuition: Music/Arts instruction, Cape Ann Museum workshop, tour of Halibut Point State Park Visitors Center and other quarry sites in Rockport, music binders, art materials, snack supplement.) For scholarship assistance please contact: Directors at CAAA, capeannartsalive@gmail.com Mentor participants (ages 13-17) may fully participate for $25.

I will mail a check to Cape Ann Arts Alive at 9 Norwood Ave, Rockport, MA 01966

I will make a payment by Venmo to @capeannartsalive

I will pay online through the tuition button on this page

This participant is Age 13-17 and is applying to be. a mentor

PERMISSION & RESPONSIBILITY *

I understand the nature of the varied activities planned for this program. I hold harmless teachers/directors from liability and claims arising out my child's participation. In the event of accident or illness, the directors have my permission to seek necessary emergency treatment if the guardian cannot be reached.

By checking this box I agree with the above statement