2017-18 SBAP Student Registration & Waiver
Please fill out this form to register yourself, child or teen for Pottery Open Workshop . Fill out a separate registration form for each child or adult.
Student Name - First & Last *
Your answer
Date of birth *
Your answer
Current Grade
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Gender *
Your answer
Home Street Address *
Your answer
City, State & Zip Code *
Your answer
Home Telephone Number *
Your answer
Work Telephone Number *
Your answer
Cell Phone Number *
Your answer
Name of Students School *
Your answer
Email Address *
Your answer
Parent/ Guardian Name *
Your answer
Parent Email Address if different from above
Your answer
Parent Guardian Employer *
Your answer
Parent Home Address (if different from above)
Your answer
Parent Home Telephone Number *
Your answer
Parent Work Telephone Number *
Your answer
Parent Cell Phone Number *
Your answer
If parents are living separately or there is another emergengy contact, use this space *
Your answer
In case of an emergeny, who should we contact if you the guardian are not available? *
Your answer
Emergent Contact - Relationship to student *
Your answer
Emergent Contact - Home telephone number *
Your answer
Emergent Contact - Work telephone number *
Your answer
Emergent Contact - Cell Phone Number *
Your answer
Physician Name *
Your answer
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. *
Your answer
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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