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ASAP Online Submission
ASAP Online Submission
Student Information
Name:
(Required)
First
Last
Name of School:
(Required)
Grade:
(Required)
Gender:
(Required)
Male
Female
Other
Age:
(Required)
Please enter a number from
7
to
17
.
Ethnicity (Optional)
White
Black
Hispanic
Asian/Pacific Islander
American Indian/Native Alaskan
Language:
(Required)
English
Spanish
Other|Otra|Autre|Outro
Choose your most preferred class options below:
This field is hidden when viewing the form
Original First Choice
First Choice (Ages 7-10)
(Required)
Monday – Mixed Fibers
Monday – Watercolor
Tuesday – Creations Station
*Tuesday – Adaptive Art [Bilingual – Spanish]
Wednesday – Culinary Creations
Thursday – Mixed Media
Second Choice (Ages 7-10)
(Required)
Monday – Mixed Fibers
Monday – Watercolor
Tuesday – Creations Station
*Tuesday – Adaptive Art [Bilingual – Spanish]
Wednesday – Culinary Creations
Thursday – Mixed Media
First Choice (Ages 10-13)
(Required)
*Monday -Macramé Design [Bilingual – Spanish]
Tuesday – Comic Illustration
*Tuesday – Adaptive Art [Bilingual – Spanish]
Wednesday – Play with Clay
*Wednesday – Macramé Design [Bilingual – Spanish]
Thursday – Comic Illustration
Second Choice (Ages 10-13)
(Required)
*Monday -Macramé Design [Bilingual – Spanish]
Tuesday – Comic Illustration
*Tuesday – Adaptive Art [Bilingual – Spanish]
Wednesday – Play with Clay
*Wednesday – Macramé Design [Bilingual – Spanish]
Thursday – Comic Illustration
First Choice (Ages 13-17)
(Required)
*Monday – Woodworking Basics [Bilingual – Spanish]
Monday – 3D Printing & Laser Design
Tuesday – Mixed Fibers
Tuesday – Dungeons & Dragons
Thursday – Procreate Dreams: Digital Animation
Second Choice (Ages 13-17)
(Required)
*Monday – Woodworking Basics [Bilingual – Spanish]
Monday – 3D Printing & Laser Design
Tuesday – Mixed Fibers
Tuesday – Dungeons & Dragons
Thursday – Procreate Dreams: Digital Animation
Parent/Guardian Information
Name:
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Language:
(Required)
English
Spanish
Other
Primary Phone Number:
(Required)
Alternate Phone Number:
E-Mail
(Required)
This field is hidden when viewing the form
Email Usage
I accept GoggleWorks’ use of my email to create an account on Padlet.
Your email will be used to create an account on Padlet.com. This account will provide access to the class page where students can share, comment, and interact with other students in the class. Class videos and discussions will also be held on this webpage.
Emergency Contact Information
Name:
(Required)
First
Last
Relationship
(Required)
Primary Phone Number:
(Required)
Alternate Phone Number:
Additional Information
Is there anything about your child you would like instructors to know (allergies, disabilities, etc.)? If yes, please let us know:
Photography and Video Footage
(Required)
I understand that my child(ren) may be photographed and video recorded during programs for legal and marketing purposes.
GoggleWorks reserves the right to use any and all photography and recorded video footage of students taken during programs for the marketing, tracking, and promotion of GoggleWorks Arts Center in print and online.
Permission to Walk (optional)
Yes, my child may walk home from GoggleWorks without being signed out by a parent or guardian.
I give my permission for my child to walk home from GoggleWorks Center for the Arts from the Fall After School Arts Program Term. By checking this box, you give your permission for your child to walk home unsupervised.
Student Liability Waiver Form
(Required)
By checking this box, you agree to the terms and conditions.
GoggleWorks Center for the Arts, a Pennsylvania non-profit corporation, is the producer of art classes for children. As consideration for, and as an express requirement of the student’s participation in GoggleWorks activities, we require, and are materially relying on the requirement that you understand and agree to a waiver of any and all claims you might have against GoggleWorks Center for the Arts its officers, directors, employees, agents, independent contractors and other representatives, as well as agree to be bound by other terms and conditions stated in this Waiver. By signing this Waiver, and to the extent permitted by law, you waive any and all claims for damages for personal injury, death, loss or property damage which you may have or which may hereafter accrue to you or your child against GoggleWorks, its officers, directors, employees, agents, independent contractors and other representatives as a result of your child’s participation in the program, and as related to the nature, type or condition of the events involved, and/or with respect to the condition of the sites involved, and/or with respect to the supervision provided, and/or with respect to the activities performed. This Waiver is signed in order for your child to participate in this activity for his or her own personal enjoyment and benefit and is done so freely with full knowledge of the risk and dangers incident thereto. By signing this agreement, you further acknowledge that you agree to assume and bear sole responsibility for these dangers and risks and to absolve and hold harmless GoggleWorks from any and all risks of any nature and kind associated with class activities. You also agree to indemnify, defend, and hold GoggleWorks free and harmless from any and all expenses, demands, claims, costs, losses, damages, recoveries, settlements, and expenses (including but not limited to interest, penalties, attorney’s fees, expert witness fees, costs, and other expenses) of any nature or kind which are incurred by the indemnity (“losses”), known or unknown, contingent or otherwise, directly or indirectly arising from or related to Staff members’ participation in program activities. This agreement hereby incorporates by reference in their entirety as if fully set forth herein, any other forms or agreements completed in the registration process. To the extent there are any conflicting terms and conditions in the incorporated agreements hereto, this Student Liability Waiver shall control and supersede any such provisions. This agreement shall represent the full and complete agreement between the parties, and any modification of the terms set forth herein shall be effective only if in writing and signed by all parties hereto. The parties to this agreement stipulate that this agreement shall be considered to have been entered into in Reading, Pennsylvania, and that any interpretation of the terms of this agreement shall be made under Pennsylvania law.
E-Signature
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
ASAP Online Submission (español)
Información del Estudiante
Nombre de Estudiante:
(Required)
Primero
Último
Nombre de Escuela:
(Required)
Grado:
(Required)
Género:
(Required)
Hombre
Hembra
Otra
Edad:
(Required)
Please enter a number from
7
to
17
.
Etnicidad (opcional):
Blanco
Negro
Hispano
Asiático/Isleño Pacifico
Indio Americano
Idioma:
(Required)
Ingles
Español
Other|Otra|Autre|Outro
Selección de clase: Por favor clasifica las opciones a continuación (primero es tu más preferido). Los estudiantes serán asignados de acuerdo a la disponibilidad.
Primera opción (7-10)
(Required)
Lunes – Fibras Mixtas
Lunes – Aquarela
Martes – Estación de Creaciones
*Martes – Arte Adaptativo [Bilingüe – Español]
Miércoles – Creaciones Culinarias
Jueves – Técnica Mixta
Segunda opción (7-10)
(Required)
Lunes – Fibras Mixtas
Lunes – Aquarela
Martes – Estación de Creaciones
*Martes – Arte Adaptativo [Bilingüe – Español]
Miércoles – Creaciones Culinarias
Jueves – Técnica Mixta
Primera opción (10-13)
(Required)
*Lunes – Diseño de Macramé [Bilingüe – Español]
Martes – Ilustración de Cómics
*Martes – Arte adaptativo [Bilingüe – Español]
Miércoles: Jugar con Arcilla
*Miércoles: Diseño de Macramé [Bilingüe – Español]
Jueves: Ilustración de Cómics
Segunda opción (10-13)
(Required)
*Lunes – Diseño de macramé [Bilingüe – Español]
Martes – Ilustración de Cómics
*Martes – Arte adaptativo [Bilingüe – Español]
Miércoles: Jugar con Arcilla
*Miércoles: Diseño de Macramé [Bilingüe – Español]
Jueves: Ilustración de Cómics
Primera opción (13-17)
(Required)
*Lunes: Fundamentos de Carpintería [Bilingüe – Español]
Lunes: Impresión 3D y Diseño Láser
Martes: Fibras Mixtas
Martes – Mezas y Dragones
Jueves: Procreate Dreams: Animación Digital
Segunda opción (13-17)
(Required)
*Lunes: Fundamentos de Carpintería [Bilingüe – Español]
Lunes: Impresión 3D y Diseño Láser
Martes: Fibras Mixtas
Martes – Mezas y Dragones
Jueves: Procreate Dreams: Animación Digital
Información del Padre/Guardián
Nombre:
(Required)
Primero
Último
Dirección del domicilio
(Required)
Dirección
Dirección 2
Cuidad
Estado
Código Postal
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
País
Idioma:
(Required)
Ingles
Español
Otra
Número de Teléfono Primario:
(Required)
Telefono Secundario:
Correo electrónico:
(Required)
This field is hidden when viewing the form
Uso de correo electrónico
GoggleWorks puede usar mi correo electrónico para crear una cuenta en Padlet.com.
Su correo electrónico se utilizará para crear una cuenta en Padlet.com. Esta cuenta proporcionará acceso a la página de la clase donde los estudiantes pueden compartir, comentar e interactuar con otros estudiantes de la clase. Los videos y las discusiones en clase estarán en esta página web.
Nombre de un contacto en caso de emergencia:
Nombre:
(Required)
Primero
Último
Relación:
(Required)
Telefono Principal:
(Required)
Telefono Secundario:
Informacion adicional
¿Hay algo sobre su hijo(a) que le gustaría que los instructores sepan (problemas médicos, etc.)? Si es así, háganos saber:
Fotografía y metraje de video
(Required)
Entiendo que GoggleWorks Center for the Arts puede usar fotografías y metraje de videos de mis hijo(s)
GoggleWorks se reserva el derecho de utilizar fotografías y metraje de video de los estudiantes para la comercialización y promoción de GoggleWorks Centro de Artes en forma impresa y en línea.
Permiso Para Caminar (opcional)
Sí, mi hijo puede caminar a casa desde GoggleWorks sin que sus padres o tutores lo firmen.
Yo doy permiso a mi hijo(s) para caminar a casa desde GoggleWorks este ASAP término. Al marcar esta casilla, usted otorga su permiso para que su hijo camine a casa sin supervisión.
Formulario de Renuncia de Responsabilidad
(Required)
Al marcar esta casilla, aceptas los términos y condiciones.
GoggleWorks, una organización sin fines de lucro en Pennsylvania, es la producción de clases de arte para niños. Como consideración y para un requisito explícito de participación de los estudiantes en las actividades de GoggleWorks, requerimos, y confiamos materialmente en este requisito, que comprenda y acepte la renuncia a cualquier reclamo que tenga sobre GoggleWorks, sus funcionarios, directores, trabajadores, agentes, contratistas y cualquier otro representante, así como cualquier otra condición escrita en el documento de descargo de responsabilidad. Cuando firma la exención, en la medida permitida por la ley está renunciando a las reclamaciones de todas las lesiones personales, muerte, pérdida o daño a su propiedad personal que los directores, empleados, agentes, contratistas y otros representantes como resultado de la participación de su hijo en el programa, y en relación con este tipo o condiciones de eventos involucrados y / o con respecto a la condición de los sitios involucrados. y / o con respeto por la supervisión prestada, y / o con respeto por las actividades realizadas. Esta exención está firmada para que su hijo participe en esta actividad para su disfrute y beneficio, y lo hace con pleno conocimiento del riesgo potencial y los peligros de las actividades. Al firmar este acuerdo, usted reconoce que acepta asumir su uso exclusivo de responsabilidad por esos peligros y riesgos y absolver y mantener a GoggleWorks indemne de todos los riesgos de cualquier tipo asociados con las actividades de la clase. También acepta identificar, defender y mantener a GoggleWorks libre e inofensivo de todos los gastos, reclamos, quejas, costos, pérdidas, daños, recuperaciones, liquidaciones y gastos (incluidos, entre otros, intereses, multas, gastos de abogados, gastos de testigos expertos, costos y otros gastos) de cualquier tipo que sean causados por la indemnización (“perdida”), conocida o no conocida, contingente de otro modo, abandono directo o indirecto, o relacionado con la participación de nuestro personal en las actividades. La aceptación por este medio incorpora por referencia en su totalidad en este documento, el historial médico y el formulario de divulgación, y el formulario de registro. Hasta que haya algún conflicto en los términos y condiciones en la incorporación de las aceptaciones al presente, la responsabilidad del estudiante controlará y reemplazará cualquier disposición. Esta aceptación representará una aceptación total entre las personas, y cualquier modificación de los términos en este documento será efectiva y solo escrita y firmada por todas las personas. Las personas en la aceptación estipulan que este acuerdo se considerará en Reading, Pensilvania y cualquier interpretación de los términos de este acuerdo de participación hecha a través de la ley de Pensilvania.
Firma Electrónica
(Required)
Primero
Último
La Fecha
(Required)
MM slash DD slash YYYY
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Capture the Future: 20th Anniversary Celebration & Fundraiser
Gallery Receptions
Spring Planter Sale
Soil & Stage: Open Mic Night
Reading Roots Market
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