ART WORKSHOP

>>>>Engaging Students in Contemporary Issues and Civic Action Through Art > > Engaging Students in Contemporary Issues and Civic Action Through Art

Sunday, March 3 10 am - 2 pm
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RETURN THIS NO LATER THAN Wednesday, February 27, 2013

Engaging Students in Contemporary Issues and Civic Action Through Art

youTHink Field Trip Permission Form I hereby grant permission for my child to participate in the following youTHink activity. Destination: Craft Date 2558 N San Fernando Rd. #B18 Los Angeles, CA 90065 Date: Sunday, March 3 2013 Departure Time: 9pm Return Time: 3pm

Please note: Submitting a permission slip does NOT guarantee your childs participation at the event. Space is limited and youTHink staff reserves the right to select students based on transportation capacity and other program considerations.
Bus /Shuttle .

I understand that transportation will be by:

I understand that adequate and appropriate supervision will be provided. I recognize, however, that unanticipated situations and problems can arise on any trip, which situations or problems are not reasonably within the control of the supervising youTHink and/or Zimmer Childrens Museum staff (including volunteers). In such instances, I agree that the Zimmer Childrens Museum and the supervising youTHink and/or Zimmer Childrens Museum staff (including volunteers) are not to be held legally responsible in the event of accident or injury and I will hold the Zimmer Childrens Museum and the supervising youTHink and/or Zimmer Childrens Museum staff (including volunteers) harmless from any costs, liability, or related expenses. I give permission for emergency medical attention to be administered should that be necessary while on this fieldtrip. I also give my permission for photos of my child taken while participating in youTHink programs to be used in promotional materials for youTHink and the Zimmer Childrens Museum, which may include an institutional video, website, or brochures. Emergency Contact Information: During the fieldtrip, I can be reached at: If unable to contact parent/ guardian, in case of emergency, please call: (name, relationship and phone number) Students name: __________________________ Address: _________________________________ Grade: _________ Email: __________________ School: ______________________________ City _____________________ State_____ Zip _________ Birth date: ______________ Date: ___ ______

Parent/Guardian(s) Signature: Print Parent/Guardian(s) Name: _______________

Home :

Cell Number: ____________________

A program of the Zimmer Childrens Museum 6505 Wilshire Boulevard #100 Los Angeles, CA 90048 Phone: (323) 761-8311 Fax: (323) 761-8990 www.youthink.org

ENTREGE ESTA FORMA ANTES DEL Miercoles 27 de febrero del 2013 Iniciando a los estudiantes en temas modernos y accin cvica a travs de Arte
Permiso para el paseo con youTHink Yo/Nosotros otorgamos permiso para que mi hija/hijo participe en el taller de arte: Destino: Craft Date 2558 N San Fernando Rd. #B18 Los Angeles, CA 90065 Por favor tenga en cuenta que presentar una forma de permiso NO garantiza la participacion de su hijo/a en el evento. El personal youTHink, reserva el derecho de seleccionar a los estudiantes en base de la capacidad del transporte y los objetivos del evento.

Fecha: Domingo 3 de marzo del 2013 Hora de Salida: 9am Hora de Retorno: 3pm Entendemos que el transporte ser a travs de:

Camin

Entendemos se proporcionar supervisin adecuada y apropiada. Reconocemos sin embargo, que pueden surgir situaciones y problemas imprevistos en cualquier viaje, problemas que no estn bajo el control del supervisor de youTHink o del Museo Infantil Zimmer (incluyendo sus voluntarios). En tales casos, nosotros convenimos en que ni el Museo Infantil Zimmer ni el supervisor o los voluntarios de youTHink y/o del Museo Infantil Zimmer debern ser hechos legalmente responsables. En caso de accidente o herida, mantendremos a todo el personal de youTHink y/o el al Museo Infantil Zimmer (incluyendo a los voluntarios) libre de cualquier costo, obligacin, o gastos relacionados a este. Yo/Nosotros otorgamos permiso para que se administre cualquier atencin mdica en caso de una emergencia durante este paseo. Yo/Nosotros tambin otorgamos permiso de utilizar fotografas tomadas durante este paseo para publicaciones y materiales promocinales de youTHink y del Museo Infantil Zimmer, al igual que videos institucionales, pgina de Internet folletos y ocasionalmente peridicos. Durante el paseo, podr ser contactada/o al: el que no sea posible contactar a padres/guardianes, favor de llamar a (como esta relacionada esta persona?
Nombre del estudiante: Domicilio __ Ciudad, Escuela: Estado,

En un caso de emergencia en al nmero To? Abuela? Etc.)

____________ Cdigo Postal: ________

Grado: ______ E-mail: _____________________ Fecha de nacimiento: ________________________ Nmero telefnico: Nombre en imprenta de padre(s)/guardin(es): Firma de padre(s)/guardin(es): Fecha: Numero celular: ______

6505 Wilshire Boulevard #100 Los ngeles, CA 90048 Telfono: (323) 761-8311 Fax: (323) 761-8990 www.youthink.org