Summer 2024: Student Info & Permissions Form

SUBMISSION DEADLINE: June 15, 2024

This form is mandatory and must be submitted prior to the program start date. Failure to do so may result in the inability to participate in future programming at Moore College of Art & Design.

Before submitting this form, you must be registered in one or more Young Artists Workshop (YAW) courses. To register, please visit our website.

Student Information

Student First Name *

Student Preferred Name

**Please note that if provided, your preferred name will be used in all communications from the College, including with parents and guardians. Otherwise, your first name will be used. You can speak with a member of our team at any time to update or change your preferred name.

Student Last Name *

Student Date of Birth *

Student Email *

Student Phone *

I would like to receive texts from Moore College of Art & Design

Student Address *

Country

Street

City

Region

Postal Code

Student Gender Identity

Student Pronouns

Student Legal Sex *

Female

Male

Non-Binary

Student Race/Ethnicity

Is the student Hispanic/Latinx?

Does this student have any allergies or medical conditions we should be aware of? *

Please specify allergies or medical conditions and list any medications this student may need in the event of an emergency

Social Security Information

Why do we ask for your social security number? Moore College of Art & Design is required to file a Form 1098-T for each student we enroll for all programs across the college and for whom a reportable transaction is made. This is a secure platform.

Student Social Security Number (without dashes) *

Parent/Guardian Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email Address *

Parent/Guardian Phone Number *

Is this the Emergency Contact for this student? *

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship to Student

Academic Information

Student Grade Level *
(Select the grade the student is entering in Fall 2024)

Student School Name *

Who referred you to the Young Artists Workshop? *

Please specify: *

Referrer Name *

Referrer Email *

Referrer Job Title *

Is the student interested in attending Moore's undergraduate program after high school? *

Course Format Confirmation

Is this student taking an IN-PERSON or ONLINE course? To confirm the format of your desired course, click here! *

Please note that all in-person classes take place at Moore College of Art & Design, located at 1916 Race Street, Philadelphia PA 19103. All online courses take place via Zoom and Moodle, Moore's online learning platform, in Eastern Standard Time (EST) from 9:00 am - 4:00 pm EST. All students will receive a unique login to the system from our team before the start of their first online class meeting.

YAW On Campus Pick Up Authorization

At the end of each class meeting, is an authorized guardian required to enter the building to sign this student out due to security, custody, or accessibility needs?

Is anyone other than the parent/guardian listed above authorized for pick up?
Only authorized adults will be allowed to pick up YAW students.

Authorized Adult First Name

Authorized Adult Last Name

Authorized Adult Phone Number

Would you like to list an additional authorized adult?

Additional Authorized Adult Name

Additional Authorized Adult Phone Number

YAW Field Trip Permission

During your child's YAW course, instructor(s) may elect to take students on a field trip for the purposes of their studio art instruction. Field trips are limited to locations near Moore College of Art & Design campus. Trips are not always announced prior to class. Students without permission will be assigned to another class for the day.

By granting field trip permission, you will hereby release, discharge, and hold harmless, Moore College of Art & Design and its officers, trustees, agents, and employees from and against all losses, claims, actions, costs, expenses, and/or damages, including attorney fees arising out of your child's participation in Moore College of Art & Design's YAW program.

I grant my child permission to participate in YAW field trips

YAW Photo Release

I hereby grant permission to Moore College of Art & Design, the rights of my child's image, in video or still, and of the likeness and sound of my voice, as recorded on audio or video tape. I understand that my child's image may be edited, copied, exhibited, published or distributed, and waive the right to inspect or approve the finished product, wherein my child's likeness appears.

Additionally, I waive any right to royalties or other compensation arising or related to the use of my child's image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for ANY USE which may include, but is not limited to:

Presentations
Courses
Online/Internet Videos
Media
News (Press)

By submitting this release, I understand this permission signifies that photographic or video recordings of my child may be electronically displayed via the Internet, or in the public educational setting. There is no time limit on the validity of this release, nor is there any geographic limitation on where these materials may be distributed.

By submitting this release, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

I grant permission to the Moore College of Art & Design

Thank you for completing this form!

How did you hear about the Young Artists Workshop? *

Questions? Please contact Moore's Office of Continuing Education at ce@moore.edu or via phone at 215.965.4030.