Art Adventures Program Form

Student's Name Student's Name First Last
Nickname
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
DOB DOB / MM / DD YYYY
Current grade in school (as of Fall 2020):
Language(s) in home:
Requested Schedule (pick one)
Does the requested schedule align with the days and times for which you will be on campus to work, teach or attend class?

Does the requested schedule align with the days and times for which you will be on campus to work, teach or attend class? Yes No
Application will not be processed unless all required information has been submitted.

A copy of the Family Handbook permissions page and a copy of the student’s TN Certificate of Immunization is required before the student’s first day at Art Adventures.
Immunization Requirement Summary for Child Care through 12th Grades
Upload the completed immunization record form

Attach Files
VCFC Art Adventures Family Handbook Agreement

Please download and read the Art Adventures Family Handbook
I have read the VCFC Art Adventures Family Handbook and agree to comply with the policies and procedures contained therein.

I have read the VCFC Art Adventures Family Handbook and agree to comply with the policies and procedures contained therein. Yes

Please answer the following questions:
Please answer the following questions:	Yes
I have been provided a copy of and thoroughly read the Art Adventures Family Handbook. I understand that a copy is also available on the VCFC website.	I have been provided a copy of and thoroughly read the Art Adventures Family Handbook. I understand that a copy is also available on the VCFC website.Yes
I understand that the Art Adventures program scheduling does not permit my child to participate in synchronous online school programs.	I understand that the Art Adventures program scheduling does not permit my child to participate in synchronous online school programs.Yes
I have read and agree to the “Use of Personal Technology” section in this Handbook.	I have read and agree to the “Use of Personal Technology” section in this Handbook.Yes
I read and understand and agree to comply with the policies and procedures which inform the VCFC services. I have communicated the behavior expectations with my child.	I read and understand and agree to comply with the policies and procedures which inform the VCFC services. I have communicated the behavior expectations with my child.Yes
I give my child permission to participate in the Art Adventures Program and I understand and agree that neither Vanderbilt Child and Family Center, Vanderbilt University, nor any of their officers, agents, or employees are liable for bodily injuries or illnesses suffered by my child(ren) or damages to personal belongings.	I give my child permission to participate in the Art Adventures Program and I understand and agree that neither Vanderbilt Child and Family Center, Vanderbilt University, nor any of their officers, agents, or employees are liable for bodily injuries or illnesses suffered by my child(ren) or damages to personal belongings.Yes
I understand that Vanderbilt cannot promise or guarantee that my child will not be exposed to Covid-19. I understand that if my child is immunocompromised my child could be at greater risk of infection and complications. I knowingly accept these risks. I understand that the illness and exposure procedures contained in the FAQ section of the program application are fluid and that procedures may change depending on the Vanderbilt Return to Campus Plan as well as DHS, Metro Nashville, and the CDC guidelines and recommendations. I understand that failure to comply may result in disenrollment of my child.	I understand that Vanderbilt cannot promise or guarantee that my child will not be exposed to Covid-19. I understand that if my child is immunocompromised my child could be at greater risk of infection and complications. I knowingly accept these risks. I understand that the illness and exposure procedures contained in the FAQ section of the program application are fluid and that procedures may change depending on the Vanderbilt Return to Campus Plan as well as DHS, Metro Nashville, and the CDC guidelines and recommendations. I understand that failure to comply may result in disenrollment of my child.Yes
I understand that VCFC reserves the right to update this Handbook at any time, to ensure compliance with Vanderbilt policies and practices and for the continuance of safety for children and staff.	I understand that VCFC reserves the right to update this Handbook at any time, to ensure compliance with Vanderbilt policies and practices and for the continuance of safety for children and staff.Yes
I give permission for my student’s image to be used in photographs and or any media from within the program’s creative space (e.g., bulletin boards, crafts, booklets.)	I give permission for my student’s image to be used in photographs and or any media from within the program’s creative space (e.g., bulletin boards, crafts, booklets.)Yes
I give permission for my student’s image to be used on the VCFC website and VU website and publications.	I give permission for my student’s image to be used on the VCFC website and VU website and publications.Yes
I have read the COVID-19 Guidelines and FAQs set forth in the program application and I agree to follow those guidelines.	I have read the COVID-19 Guidelines and FAQs set forth in the program application and I agree to follow those guidelines.Yes

Allergies, seizures or other medical condition(s)
Pediatrician
Pediatrician's phone number Pediatrician's phone number - ### - ### ####
Pediatrician's Address Pediatrician's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent/Guardian #1
Name Name First Last
Email
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
VU ID#
Job Title
Department
Parent/Guardian #2
Name Name First Last
Email
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
VU ID#
Job Title
Department
Emergency Contact #1
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Other
Emergency Contact #2
Name Name First Last
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Other
Do you have a friend that you would like to be paired with?

Do you have a friend that you would like to be paired with? Yes No
VCFC does not guarantee peer pairing, but will consider requests:
My friend My friend First Last
Who is age
is also applying for Block
On the following days
Student Facts
Favorite book(s):
The thing I am great at:
One interesting thing about me:
All persons picking up any child from VCFC must be at least 18 years of age
and be prepared to present their government issued photo ID upon staff request.
I have read and our family agrees to abide by the Art Adventures program policies and procedures, including health and safety protocols contained within the Family Handbook, on this application form, and in the following COVID guidelines.

I have read and our family agrees to abide by the Art Adventures program policies and procedures, including health and safety protocols contained within the Family Handbook, on this application form, and in the following COVID guidelines. Yes
Parent/Guardian signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Art Adventures Program Form

Art Adventures Program Form

Application will not be processed unless all required information has been submitted.

VCFC Art Adventures Family Handbook Agreement

Parent/Guardian #1

Parent/Guardian #2

Emergency Contact #1

Emergency Contact #2

VCFC does not guarantee peer pairing, but will consider requests:

Student Facts

All persons picking up any child from VCFC must be at least 18 years of age and be prepared to present their government issued photo ID upon staff request.

All persons picking up any child from VCFC must be at least 18 years of age
and be prepared to present their government issued photo ID upon staff request.