Application: 2019 Winter & Spring Workshops
Please fill out the following registration and participation agreement form for each child you are registering. If you are registering the same child for multiple camps, you need to fill this form out only once. Please note, registration is not complete until you submit payment. Thank you!
Student Name *
Your answer
Which camps are you registering for? *
Check all that apply.
Required
Date of Birth *
MM
/
DD
/
YYYY
School *
Your answer
Residency *
Grade (Fall 2018) *
Preferred Gender *
Your answer
Parent/Guardian Name *
Your answer
Relationship to student *
Your answer
Parent/Guardian's Phone Number *
Your answer
Parent/Guardian's Email *
Your answer
Student Email (if applicable)
Your answer
Street *
Your answer
City *
Your answer
State *
Your answer
Postal Code *
Your answer
How did you hear about this workshop? *
Past filmmaking experience of student (if any):
Your answer
What does the student hope to gain from this workshop?
Your answer
Has the student taken a workshop/camp at Light House Studio before? *
Questions about the student's background
We would appreciate your taking the time to fill out the following questions about the participating student, to help us in our mission to ensure we serve a diverse group of students.
Which languages besides English, if any, does the student speak at home?
Your answer
Does the student qualify for free or reduced lunch at school?
What is the student's race?
Participation Agreement
Parents/Guardians: Please fill out the following Participation Agreement for your child. Thank you!
I, the undersigned parent or legal guardian of the minor(s) listed: *
First and Last Name of student minor
Your answer
Make the following certifications: *
A. Medical Release. I/we do hereby give authorization and consent for medical treatment in the event my child becomes ill or injured during a Light House Studio, Inc. (“Light House”) Workshop. Light House Staff or persons working on its behalf are authorized to take one or more of the following actions for my child (children): 1) provide reasonable basic first aid; 2) release my child (children) to the emergency contact person listed below; 3) take my child (children) to a physician or call the physician indicated; or 4) take my child (children) to the hospital and/or give consent for emergency care.
Person IN ADDITION to parent or guardian to contact in emergency: *
Please list the emergency contact's name
Your answer
Relationship of additional contact person: *
Your answer
Phone Number: *
Your answer
Doctor's Name *
Your answer
Doctor Office Address *
Your answer
Doctor Phone Number *
Your answer
Please indicate any significant health history of which Light House should be aware: *
Your answer
Please list all allergies and/or medications: *
Your answer
Please list any additional information that would be helpful for our staff to know about your child:
Your answer
By typing my name at the end of the form, I hereby certify that my child is in good health and may participate in all Light House activities and that I have read and consent to the medical authorization (A). *
By typing my name at the end of this form, I agree to the following: *
B. Off Site Release: My child (children) has my permission to leave the main workshop location under the supervision of persons working on behalf of Light House to participate in workshop activities at other locations designated for such activities by Light House.
By typing my name at the end of this form, I agree to the following: *
C. Public Relations and Intellectual Property Release: I hereby permit Light House Studio to use, in whole or in part, photos, videos, written extractions and voice recordings of my child (children) for the purpose of illustrations, publications, media relations and film festivals. By signing this document, I assign to Light House all rights, title, and interest, including, for example, copyright, moral rights, rights of attribution, and other rights of ownership, in and to the photos, videos, written extractions and voice recordings and all materials resulting therefrom. I agree that Light House owns all rights in and to the photos, videos, written extractions and voice recordings and that Light House may obtain in its name a copyright in any materials or production of the photos, videos, written extractions and voice recordings.
By typing my name at the end of this form, I agree to the following: *
D. Accident/Injury Release: I hereby release and agree to indemnify and hold harmless Light House Studio, its agents, employees, officers, and directors from any and all responsibilities and liability for injuries to my child (children) while he/she is enrolled in a Light House Workshop.
By typing my name at the end of this form, I agree to the following: *
E. Enrollment Agreement: Light House reserves the right to dismiss any child whom it determines in conduct, industry, or progress proves unsafe or disruptive to any given workshop.
By signing below you authorize your child to travel, wearing appropriate safety belts, in a vehicle with a licensed and insured Light House Teaching Artist or Staff driver at least twenty-one years of age within Charlottesville and Albemarle County. *
Please type your name, the date, and your child's name as a signature of acceptance of these terms. ***Campers in 3rd-5th grade will not be traveling in vehicles***
Signature *
Please type your name as your signature in agreement and understanding of all sections described above.
Your answer
Date *
Your answer
Are you applying for financial assistance? *
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