2017 SBAP Student Registration & Waiver
Please fill out this form to register yourself, child or teen for Pottery Open Workshop . Please fill out a separate registration form for each child or adult.
Student Name - First & Last
Date of birth
Current Grade
Gender
Home Street Address
City, State & Zip Code
Home Telephone Number
Work Telephone Number
Cell Phone Number
Name of Students School
Email Address
Parent/ Guardian Name
Parent Email Address if different from above
Parent Guardian Employer
Parent Home Address (if different from above)
Parent Home Telephone Number
Parent Work Telephone Number
Parent Cell Phone Number
If parents are living separately or there is another emergengy contact, use this space
In case of an emergeny, who should we contact if you the guardian are not available?
Emergent Contact - Relationship to student
Emergent Contact - Home telephone number
Emergent Contact - Work telephone number
Emergent Contact - Cell Phone Number
Physician Name
I give my doctor permission to treat my child/ren in case of an emergency
This student has the following special needs (consider medications, allergies, physical and mental health, behavior or emotional problems, and anything else that will help us serve this student.
RELEASE/WAIVER: I hereby agree to indemnify and hold harmless South Broadway Art Project and its employees from and against any and all claims for personal injuries or damages of any kind arising from participation in the SBAP program. Further, I authorize SBAP staff and faculty to seek emergency medical help if this becomes necessary. I realize that every effort will be made by SBAP staff to contact me in the event of a medical emergency involving my child and I agree to indemnify and hold harmless SBAP personnel in seeking medical care for my child. PHOTO CONSENT: By your signature, you agree that SBAP may use the above named students photograph in the routine promotion of its classes and activities and other non-commercial applications. Please agree to these terms by checking the YES box below. Questions, please call 314-324-2713
Required
E-Signature: Parent/Guardian - Please type signature below. Registration is not complete without your signature.
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