School Distrct: Genesee Intermediate School District

Name of Program:
Select Elmer Knopf Learning Center Elmer Knopf Learning Center - Project CHOICE Early Childhood Programs and Services Early Childhood Programs and Services - Project CHOICE Marion Crouse Instructional Center Other

Please put your cursor on the left-hand edge of each form item
to bring up the type cursor.

Staff Persons, Contact Info, Class Size and Number of Students:
Name of Staff Person 1:
Name of Staff Person 2:
Name of Staff Person 3:
Name of Staff Person 4:
Address:
City: State: Zip:
Daytime Phone: Evening Phone:
Fax:
Name of Administrator:
Number Of Students:
Ages Of Students (please specify age range):

Types Of Disabilities:

Briefly Describe Student's Strengths:

Physical Or Other Adaptions Needed:

Does your group have access to any arts activities on a regular basis?

Have You Participated In VSA Activites Before?
Yes:
No:

From what arts media do you believe your students would most benefit?
Choose all that apply by highlighting each one (Ctl - left-click for Windows, Command-Apple-click for Mac:
Visual Art Story Telling Music Creative Movement Drama

Why?

How Do You Intend To Integrate The Arts Into Your Curriculum?

I would like to volunteer for the following Fundraising events: (Follow the same instructions to choose more than one as with the arts media benefit menu)
- Barnes & Noble Book Fair - Prepare art works for exhibit - February 2010 - Set up exhibit at Flint Children's Museum March 4 & 5, 2010 - Dismantle art exhibit at Flint Children's Museum - March 20, 2010 - Work at VSAMI-GC booth at Autism Walk - May 29, 2010 - Volunteer on bulding VSA festival Committee - Volunteer on the District Committee
Please note: If you are volunteering on the Festival Committee, click the radio button next to that person's name:
Carol Vassler, ECPS:
Carolyn Vierkorn, MCIC:
Kathy Cole or Jill McCarthy, EKLC:
Randee Pieper, EKLC Project CHIOCE:

If you are volunteering on the District Committee, note that the monthly meetings are from 3:30 to 5 p.m. on the second Wednesday of the Month.

Other (for something not on this list) - Please Specify:

Festival T-Shirt Order Form: EKLC, EPCS and Project CHOICE classrooms only. Student/Participant/Volunteer Shirt Sizes Needed:

Youth Sizes:

XS
Small
Medium
Large

Adult Sizes:

Small
Medium
Large
XL
XXL
XXXL

Please register your GISD classroom via our online registration form or via our print registration form, and make sure your check for the $10 registration fee, plus $1 for each participant is made out to VSAMI-GC:
Please address checks to VSAMI-GC.
Send payment to:
Carolyn Vierkorn
VSAMI-GC
Marion Crouse Instructional Center
2413 W. Maple Avenue
Flint, MI 48507

Registration fees: $10 per classroom - enter number of classrooms
and $1 per student materials fee - enter number of students
Entries in both boxes are required.

Note: please make a print copy of the form for yourself prior to sending.