SiO2 Intake Form

"*" indicates required fields

Student Contact Information

Student Name*

First Last

Student Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Age*

Pronouns*

What school does your young artist attend?*

Grade*

In which youth class is your young artist currently enrolled?*

Has your young artist attended programs at PGC before?*

Please tell us which classes, workshops, or programs.

Primary Contact Information

Primary Contact Parent/Guardian Information (authorized to pick up student)

Name*

First Last

Email*

Cell Phone*

Home/Office Phone*

Address

Secondary Contact Information

Parent/guardian information (authorized to pick up student)

Name

First Last

Cell Phone

Home/Office Phone

Additional Contacts

Please list any other individuals authorized to pick up your student from Pittsburgh Glass Center programs. Anyone picking up your student may be asked to show a photo ID before your student will be allowed to leave with them.

1st Sign Out Designation

Name

First Last

Cell Phone

2nd Sign Out Designation

Name

First Last

Cell Phone

3rd Sign Out Designation

Name

First Last

Cell Phone

Student Medical Information

Please note that PGC staff are not permitted to dispense medication. Medication lists are only for situations if we need to seek emergency care for young artists.

Primary Care Physician Name*

Primary Care Physician Phone*

Does your child have any known allergies?*

If yes, please explain.*

Does your child carry an epinephrine auto injector?*

Does your child need to take a prescripition or over-the-counter medication during program hours?*

If yes, please list any medications and reason for taking.

Additional information you think we should know.

PGC Practices and Policies

Please read the practices and policies below. Sign on behalf of your young artist attending a class at Pittsburgh Glass Center (PGC).

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Name

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