Rise Up Yoga Sign-Up
JUDSON FALL SESSION: THURSDAY SEPTEMBER 26, 2019 - JANUARY 30, 2020 (3:30-5:00 PM)

Note: There is a limit of 25 children per session.
Child's Last Name *
Your answer
Child's First Name *
Your answer
Emergency Contact (Name and Phone Number) *
Your answer
Parent/Guardian Email: *
Your answer
Please list individuals that will be picking up your child from Kids RISE Up. IDs will be checked for safety: *
Your answer
Would you like to receive emails from Lotus Counseling regarding upcoming yoga and wellness events? *
Please provide us with any special concerns/needs your child may have. This program is run by a Licensed Professional Counselor, and the goal is for ALL children to attend and benefit. Let us know how we can best help your child:
Your answer
Please initial the following statement: I understand and agree that Kids RISE Up is a program run through Lotus Counseling of Connecticut and sponsored by the Watertown Youth Service Bureau. I understand that the school is not responsible for Kids RISE Up and that all questions and/or concerns should be directed to Ms. Kait Marcil of Lotus Counseling. *
Your answer
Please initial the following statement: Statement of Liability: I understand that my child will be participating in an after school program using yoga and mindfulness. 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, its 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. *
Your answer
Please initial the following statement: 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. *
Your answer
Please initial the following statement: I hereby give Lotus Counseling permission to photograph/video my child for marketing and promotion purposes. I understand that I will not be compensated for my child’s photo. *
Your answer
Parent signature indicating that all the above statements were read and understood and that you agree to have your child participate in Kids RISE Up. *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Watertown Public Schools. Report Abuse - Terms of Service