Art Student Application
Hearts of Mercy’s Art Program is free to  qualifying families.  Any family who doesn't meet the requirements for the free program may enroll with a $20 a class suggested donation. All students are required to pay a $25 registration. 
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Child's First and Last Name *
Child's Date of Birth *
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Guardian's First and Last Name *
Relationship to child *
Required
Guardian's phone number (Cell) *
Guardians email address *
Additional Guardian
Additional Guardian Cell Phone Number
Relationship to child
Student Home address *
Emergency Contact Name/Phone/ Relationship to child *
Siblings *
What is the primary language spoken at home? *
Grade *
Does your child like art? *
Has your child ever had art classes? *
Is your child receiving reduced or free lunch in school? *
Are you eligible for SNAP? *
I agree to provide proof of SNAP or TANF assistance. *
Does your child suffer any allergies? Please explain: *
Are there any special needs (Medical Conditions, Learning Disabilities, Physical Disabilities, etc) If yes, Please list *
In case of emergency, may we have your child transported to the hospital?   *
Are there custodial issues?   *
If yes or maybe, please explain
What is your ethnicity? *
Are you and /or your child interested in:
Tutoring Program Parent/Child Agreement                        As a parent, I support my child’s participation in the Hearts of Mercy art program. I agree:
Volunteers are always needed. Would you be willing to volunteer?
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Are you interested in a special women's empowerment program we may offer?
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Would you be willing to give a testimonial on our behalf to give others an idea of how we can help?
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Parent/Guardian Signature: Fee structure- This information is true and current to date to the best of my ability. I understand that I may be required to provide proof of assistance and I will be paying the per class fee based on my eligibility. 
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Parent/Guardian Signature:   Medical Consent
I take responsibility of alerting any representative of Hearts of Mercy of my child's change in health status, including and not limited to their ability to attend classes due to common cold and flu virus as well as a potential covid 19 exposure. I understand that by attending these events I am risking exposure to Covid 19 and hold Hearts of Mercy harmless in the event of an exposure. In the event emergency contacts or parents cannot be contacted, Hearts of Mercy officials are hereby authorized to take whatever action is deemed necessary in their judgment, for health of the aforesaid child. I will not hold Hearts of Mercy financially responsible for the emergency care and/or transportation for said child. (Please write name below)
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Parent/Guardian Signature: Liability Release
I give my consent for my child to participate in activities with Hearts of Mercy. I understand that Hearts of Mercy has done their due diligence to ensure my child's safety and assume full responsibility for supervision of the minor for these activities.  As a condition for my child to participate in the activity, I hereby expressly hold Hearts of Mercy harmless and waive all claims which I or my child may have against Hearts of Mercy, their officers, agents, employees and directors, arising from injury, accident, illness or death occurring during or by reason of directly or indirectly participation in the activity, including transportation to and from if necessary. I hereby attest that I am at least eighteen years of age, have personal and legal custody of the minor child and have read, understand and agree to the above provisions. (Please write name below)
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Parent/Guardian Signature: Photo Release
I grant Hearts of Mercy, my permission to photograph, videotape, and/or audiotape my child during activities run by HOM. These photographs/videos/audios will remain the property of HOM and may be used in advertising or marketing campaigns on HOM’s websites, and for promotional and informational material including, but not limited to, flyers, brochures, newsletters, emails, advertisements, & newspaper articles. I understand my child will not be identified by name unless I give my express permission. I hereby waive and release on behalf of my child, any rights to compensation for, or ownership of, such images and/or sounds. I have read and agree to the terms and conditions of this Photo, Media and Copyright release.
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Date *
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