Autism Arts Yarmouth - Summer 2022 Registration

Ages 6-9 (9:15am-10:15am) Tues July 26 & Thurs July 28 - $0.00 CAD Ages 13+ (9:15am-11:45am) Mon July 25, Wed July 27 & Fri July 29 - $0.00 CAD Ages 10-12 (10:30am-11:30am) - Tues July 26 & Thurs July 28 - $0.00 CAD

Guardian Contact Name: First & Last Name

Guardian Contact Phone Number:

Guardian Contact Email:

Participant 1 Name: First & Last Name

Participant 1: Date of Birth (YYYY/MM/DD)

Participant 2 Name: First & Last Name

Use NA if not applicable.

Participant 2: Date of Birth (YYYY/MM/DD)

Previous Participant(s). Has the participant(s) attended this program previously?

Please choose oneYesNo

Audio/Visual Consent. Photos and videos, may be gathered during our studio and Gallery programs. Please indicate your consent or refusal to allow the Art Gallery of Nova Scotia to use this data for promotional materials (in print, on website or social media). Note children’s name and personal details will not be shared.

Please choose oneYes, I hereby give consent. No, I do not give consent.

Other Information. Use this space if you are registering more than than two participants to provide: Name, Age, and other required information. Use N/A if note applicable.

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