March Break Camp | 11-15 March | Kitchener-Waterloo Art Gallery

Please complete the fields below to register for March Break Camp from 11-15 March 2019:

How many people are you registering? *

Fill in your registration information on this page. If you are registering additional people, you will be able to enter their registration information after you complete this page and click "Continue".

Your Registration Details

Please be aware of our registration/cancellation policy before signing up.

First Name *

Last Name *

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Phone

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Street Address *

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Select this option to receive KWAG Weekly e-newsletter for information on future programs and events. You may unsubscribe from our mailing list at any time by clicking the unsubscribe link at the bottom of our emails.

Credit Card Information

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Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

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Child Registration Details

Child's first name

Child's last name

Child's gender

female

male

other / prefer not to answer

Child's birth date

Child's grade

Please provide name and telephone number

Child's family physician

Please detail any health or emotional concerns, including allergies, that the Gallery should be aware of. Will your child be bringing any medication to the Gallery? Does he/she carry an EpiPen?

Medical notes

Please provide the parent(s)/guardian(s) name and telephone number

Parents/guardians

Emergency contact (name and telephone number) in the event that parent(s)/guardian(s) cannot be reached

Emergency contact

How did you hear about this program?

Referral