To enroll in classes at The Paintbrush, you can call us, email us or fill out and print the form below and mail it along with payment. (You can also save this form as a PDF and print it.)
2856 N. Halsted ~ Chicago, IL 60657
773.636.1968 ~ www.thepaintbrush.net
Student Information Form
(this form must be received by The Paintbrush prior to your child’s first class)
Child’s Information
Child’s name (last)___________________________ (first)___________________
Birth Date _________________ Grade in school_____________________
The Paintbrush class day and time ___________________________________________________
The Paintbrush class start date ______________________
OR
U-Pick 8 Summer CLASSES (circle 8 dates)
Tuesdays 2:15
6/17 6/24 7/1 7/8 7/15 7/22 7/29 8/5 8/12 8/19
Wednesday 2:15
6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Wednesday 3:50
6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Thursday 4:00
6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
OR SUMMER CAMP
OR Summer CAMP (circle weeks or individual days)
June 16-20 6/16 6/17 6/18 6/19 6/20
July 14-18 7/14 7/15 7/16 7/17 7/18
August 18-22 8/18 8/19 8/20 8/21 8/22
Emergency & Medical Information
Parents’ Names _______________________________________
Home address ________________________________________
City________________ Zip ______________
Home phone __________________________________________
Cell phone ___________________________________________
Email address _________________________________________
Emergency contact (other than parent):
____________________________________________________
Emergency phone ______________________________________
Pediatrician name ________________________ phone _________________________
Does your child have any medical conditions of which The Paintbrush should be aware? If so, please explain:
____________________________________________________
Who will be bringing your child to/picking your child up from class?
______________________________________________________
Safety and Waiver Release
Please read carefully and sign at the bottom.
Safety & Insurance Coverage The Paintbrush makes every attempt to conduct programs safely. Participants are expected to follow safety rules and instructions, which were designed for participants’ protection. The Paintbrush carries general liability insurance for its operations; however, please be advised that The Paintbrush does not carry medical insurance for accidental injuries sustained in its programs. Therefore, each person registering himself/herself or a family member should review his/her own health insurance policy for coverage.
Waiver & Release The Paintbrush does not accept responsibility for injuries, damages or loss that participants may suffer while participating in The Paintbrush classes. Accordingly, I agree to assume the full risk of any physical injuries, damages, or loss, regardless of severity. Which I or my child may sustain as a result of participating in any or all activities connected with or associated with The Paintbrush. On behalf of myself, my spouse and my child, I hereby waive, relinquish, fully release and discharge, and further agree to indemnify, hold harmless against and defend The Paintbrush (including its owners, officers, directors, servants, employees and landlords) against all rights, claims, causes of action and liabilities of any sort that I or my child may have now or in the future, including but not limited to, any claims for personal injuries, medical expenses, property damage, or losses sustained by me or my child arising out of, connected with or in any way associated with the activities of any programs at The Paintbrush.
Permission to Secure Treatment In the event of emergency, I authorize The Paintbrush officials to secure from a licensed hospital, physician and or medical personnel any treatment deemed necessary for my or my child’s immediate care, and agree that I will be responsible for payment of any and all medical services required.
Use of Photographic Images All participants agree that any photography or video taken while participating in a class, special event, or use of facility may be used for promotional purposes for The Paintbrush.
I have read and fully understand the above information and regarding Safety & Insurance Coverage, Waiver & Release, Permission to Secure Treatment, and Use of Photographic Images.
Parent/Guardian Signature _________________________________________ date _________________
In addition to above named parent(s), who may pick up your child from The Paintbrush?
Name: _____________________________ Relationship: _________________________________
Name: _____________________________ Relationship: _________________________________
Name: _____________________________ Relationship: _________________________________
Please let instructor know when someone other than yourself will be picking up your child from The Paintbrush.
The Paintbrush Summer CAMP date(s) (please circle)