Request edit access
Creative Arts Therapeutic Group 2019
SATURDAYS: April 6th, 13th, 20th, 27th
10 AM- 11 AM
Investment: $60
No Refunds Available Unless Emergency
Email address *
Guardian Name *
Email *
Phone Number *
Emergency Contact (Name + Number) *
Child Name *
Age and Grade *
Please tell us anything you'd like us to know about your child
I understand that registration is not complete until payment is made. I agree to pay via PayPal invoice by 4/5/19 to secure my child's spot. This invoice will be sent to you once registration is received. *
I understand that my child will be participating in a workshop that will include gentle movement (yoga and stretching). I understand that these activities require physical movement and bodily exertion which may result in an accident of physical injury. In order to allow my child to participate in this activity, I hereby release and indemnify Lotus Counseling, it’s employees, and any instructors from and against all claims, liabilities, damages, or causes of action arising out of or in connection with my child’s participation in the classes, without limitation. *
I hereby give consent for emergency care prescribed by a licensed Doctor of Medicine in case of emergency. This care may be given under whatever conditions are necessary to preserve the well-being of my child. *
I hereby give Lotus Counseling permission to photograph my child for marketing and promotion purposes. I understand that I will not be compensated for my child’s photo. *
Never submit passwords through Google Forms.
This form was created inside of Lotus Counseling of Connecticut. - Terms of Service