Register for Camp!

Student's FirstName:

Student's LastName:

Student's Age:

Student's Birthdate:

Student's School:

Student's Grade:

Parent(s) First Name(s):

Parent(s) Last Name(s):

Home Phone:

Cell Phone:

Work Phone:

Address:

City:

State:

Zip Code:

Your Email:

Emergency Contact:

Emergency Contact Phone:

Person Allowed to Pick up my Child:

Child Allergies/ Special Needs:



The above enrolled student has my permission to participate in all the activities offered at the Portside Arts Center.
I authorize the Portside Arts Center to take the necessary steps to insure my family’s health and safety in case of an
emergency. Furthermore, I agree to hold the Portside Arts Center and it’s instructors free and harmless from
damages to property or injury sustained by participation that results from operation of the program. I also
authorize the Portside Arts Center to use my family’s name, and photographs for educational or public relation
purposes related to the Portside Arts Center.


Date:



(215) 427-1514

portsideartscenter@gmail.com

2531 E. Lehigh Avenue

Philadelphia, PA

19125

Portside Arts Center depends on community support and involvement and volunteerism to be able to continue supplying the community with quality arts enrichment. If you would like to volunteer to help with festivals, fund raisers, administrative tasks or grant writing. Please contact us.

Please donate to us through the Southeastern United Way
Donor Choice Program #48860
Make our mission yours!

Portside Arts Center is a non-profit 501(c)(3) organization.

Designed by The Art Institute of Philadephia