Week Four│ Ages 10 - 13 | Kitchener-Waterloo Art Gallery

Please complete the fields below to register for Summer Art Camp 2023:

How many people are you registering? *

Your Registration Details

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

First Name *

Last Name *

Email Address *

Phone

Country *

Province *

Street Address *

City *

Postal Code *

Newsletter sign-up *

Yes No

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.

I hereby authorize any images of the registered participant and any media material created by the registered participant during Kitchener-Waterloo Art Gallery programs to be displayed on the Kitchener-Waterloo Art Gallery Website and social media platforms, and to be used for external media purposes including marketing campaigns and promoting our recreational programs. (For participants under legal age - guardians must agree or decline permissions)

Photo Permission *

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

Child Registration Details

Child's first name

Child's last name

Child's pronouns

she/her/hers

he/him/his

they/their/theirs

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