2017-2018 Registration 2017-2018 Registration Step 1 of 3 33% Participant Contact InformationParticipant Name* First Last Participant Email* Experience*This is my first ArtStream class (all information required)I have taken classes before and am updating my information.My information is on file and accurate. (Please scroll down to "Participant Confidential Information" to continue)How did you hear about ArtStream?Participant PhoneParticipant CellParticipant Address Street Address City State / Province / Region ZIP / Postal Code Participant DOB Participant GenderMaleFemaleParticipant Confidential InformationConfidential Information*My confidential information is on file and accurate. (Please scroll down to "Emergency Contact Information" to continue)I'm updating my confidential information.Confidential InformationFood allergies, medical needs, or other special needs of the participant (allergies, medications, or physical, cognitive, or emotional disabilities).Possible Coping MethodsHow can a teacher know that the participant is uncomfortable? What phrases are best for encouraging positive behavior?Special SkillsAny special skills or affinities that the participant may wish to share?Emergency Contact InformationEmergency Contact Information*My emergency, transportation, and billing contacts are on file and accurate. (Please scroll down to "Next" to continue to the next page)I'm updating my contacts.Emergency Contact (EC) First Name Last Name EC Relationship with ParticipantEC Email EC PhoneEC CellEC Address Street Address City State / Province / Region ZIP / Postal Code Transportation Contact (if different from EC) First Last RelationshipTransportation Contact PhoneTransportation Contact Email Metro Access IDBilling Contact (if different from participant or EC) First Last RelationshipPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Registration InformationClass*Inclusive Music and Movement in North Bethesda,MD (Free)Super Social Saturday in Germantown,MD ($30.00/session)Super Social Saturday in Oakton,VA ($30.00/session)Acting Games for Fun and Focus in Gaithersburg, MD ($280.00)Broadway Song & Dance in Fairfax, VA ($490.00)NOTE: Think On Your Feet (Winter) in Reston, VA is registered at www.restoncommunitycenter.com.I am:*A current Mason LIFE participantA past Mason LIFE participantNot a Mason LIFE participantPlease select how many sessions you are registering for.*1 Super Social Saturday2 Super Social Saturday3 Super Social Saturday4 Super Social Saturday5 Super Social Saturday6 Super Social SaturdaySuper Social Saturday in Germantown* November 18: Sci-fi (WAITLIST) December 16: Nature January 20: Be Our Guest February 17: Valentine's Day March 17: St. Patrick's Day April 21: Uptown Funk Please select which sessions you are registering for.Super Social Saturday in Oakton* December 2: Nature January 6: Be Our Guest February 3: Valentine's Day March 3: St. Patrick's Day April 7: Uptown Funk Please select which sessions you are registering for.Payment Method*Online and credit card payments require a 4% convenience fee. Pay in Full Offline - I would like to pay by checkPay in Full Online - I would like to pay in full online (4% additional fee)Alternate payment optionsPlease send payment to our new address at: ArtStream, Inc. 8401 Connecticut Ave, Suite 1230 Chevy Chase, MD 20815 Checks payable to ArtStream, Inc. Include participant's name in the memo line.Alternate Payment Options*I would like to pay in installmentsI would like to request tuition assistanceI will be contacting my provider to help pay for tuitionArtStream services are eligible for LISS and Respite funding, or may be approved by other service providers. Participants must submit funding requests directly to their provider; ArtStream is not responsible for communicating with providers unless pre-arranged. If the provider agency approves partial funding or denies funding, the participant is responsible for any remaining balance.Limited financial aid may be available. We will follow up upon submission of this form.Participants may pay in up to three (3) installments. The first payment must be made within 7 business days of registration confirmation. A confirmation email will detail the installment dates and amount. Please send payments, made payable to ArtStream, Inc. and with the participant's name on the memo line, to our new address at ArtStream, Inc.8401 Connecticut Ave, Suite 1230Chevy Chase, MD 20815 Processing Fee Price: $0.00 Total $0.00 ArtStream Program Participation PoliciesPlease check all fields below to indicate that you have read and agree to ArtStream's policies.Participation*I agree to participate fully. Unless otherwise noted, ArtStream programs are open to adults (18+) with intellectual and developmental disabilities (IDD) – including autism – and other social and behavioral needs. Participants should be able to function in groups of up to 30 people with 1:4 staffing; independently meet self-care needs; follow directions; and demonstrate respectful, safe behavior at all times.Behavior and Safety*I agree to be respectful and safe. ArtStream reserves the right to determine any individual’s participation in an ArtStream program. In the event of a behavior incident or an accident, ArtStream will prepare an incident report and contact the participant’s parent or guardian. For ongoing unsafe, defiant or other problematic/inappropriate behavior, a participant may be placed on a behavior contract or dismissed from the program. ArtStream has a zero-tolerance policy for drugs, alcohol or weapons on site; self-harm; and threats, violence or harassment of any kind. A participant exhibiting or engaging in any of these behaviors or activities may be dismissed from the program. Any participant threatening to harm oneself or others may be required to have a mental health assessment before further participation in an ArtStream program.Registration*I agree to the registration policies Registrations are processed on a first come, first serve basis. Registration may be submitted by mail or online at art-stream.org. Registration should be submitted at least two (2) weeks in advance; if registering late, call the ArtStream office to confirm availability. Individuals may be added to the wait list if the program is full. Registration is not valid, nor is a spot guaranteed, until any previous balance is paid and a registration form is received with an initial payment or approved alternate payment option (below). A confirmation email will be sent when a spot in the program is reserved for the participant. Once registration is confirmed, the participant is responsible for the cost of tuition. Tuition will not be prorated for planned or unplanned absences.Payment*I agree to the payment policies and schedules. Payment Due Dates: If paying in full in one payment, tuition is due within fifteen (15) business days of the first session of class. If a participant is paying in installments, the first payment is due within seven (7) business days of registration. Payments for Super Social Saturday must be received by the Thursday prior to each session. Payments must be sent to the ArtStream office. Alternate Payment Options: ArtStream makes every effort to accommodate all participants regardless of their ability to pay. Alternate payment options available to all participants are listed below. Please contact us for other payment arrangements.Provider Agency: ArtStream services are eligible for LISS and Respite funding, or may be approved by other service providers. Participants must submit funding requests directly to their provider; ArtStream is not responsible for communicating with providers unless pre-arranged. If the provider agency approves partial funding or denies funding, the participant is responsible for any remaining balance.Installments: Participants may pay in up to three (3) installments, with the first payment made with registration or within seven (7) business days of registration confirmation. An installment plan will be designated with registration and varies by the length of class. For an average eight-week class, installments are due with registration, at the 4th week, and before the 6th week of class.Tuition Assistance: Participants in need may request tuition assistance as a final resource. Funding availability is not guaranteed. Cancellations*I understand the cancellation policies and that classes may be cancelled.If a participant wishes to cancel registration, requests must be submitted in writing prior to the second class session; the participant will be responsible for the cost of sessions held, and refunded for any additional tuition paid. After the second session, participants will be responsible for the full cost of tuition. Online processing fees are nonrefundable. Registration will automatically be cancelled for participants who miss the first two class sessions without advance notice so as to allow individuals from the wait list to join the program.ArtStream and its partners reserve the right to cancel programs due to low enrollment or other unforeseen circumstances. If a program is cancelled in its entirety, participants will be fully refunded for all sessions not held. In the event of inclement weather or other emergencies, ArtStream will notify participants via email, phone, and the ArtStream website, Facebook and Twitter. ArtStream will make every effort to notify participants at least three (3) hours before a session, but sessions may be cancelled with little or no notice. Participants will not be refunded for emergency cancellations. Participant safety is ArtStream’s first priority; if a participant feels unsafe to travel due to weather conditions, they should contact their instructor.Communication*I agree to provide accurate information Participants, parents or legal guardians are responsible for providing ArtStream with current contact and/or medical information.Liability Waiver*I release ArtStream of liability. ArtStream aims to provide a safe environment, but there is always a risk of accident or injury. Each participant, parent or legal guardian is responsible for all medical bills or other costs for illness or injury related to participation in an ArtStream program. Participants must be covered by their own accident and medical insurance. By signing an ArtStream registration form, participant releases and indemnifies ArtStream and its partners from all liability for any claims or damages arising out of participation.Photo Release*I agree to have my picture taken at classes. ArtStream and its partners have permission to use photographs, audio and video of classes and performances for any purpose, including promotional, educational and commercial use.Research Consent*I give permission to conduct group evaluations. ArtStream may conduct group evaluations in order to assess the quality of ArtStream programming. Any group evaluation is completed anonymously and reviewed in aggregate with no personal identifiers. The purpose of these evaluations is to improve ArtStream classes and results. Participation in this evaluation is voluntary. ArtStream participants or their legal guardian may choose not to participate or to withdraw from the evaluation process at any time, without affecting registration, class participation or future participation. Your signature on the registration form gives ArtStream permission to conduct group evaluations and use the aggregate, anonymous information for promotional, educational, course improvement, or fundraising uses.Participant or Parent/Guardian Signature*Please type your name to confirm that the information provided above is correct and agreed upon.