Family Emergency Form
This form must be completed in its entirety/turned in for registration to be complete.
Student #1 - Name: *
Your answer
Student #2 - Name:
Your answer
Student #3 - Name:
Your answer
Student #4 - Name:
Your answer
Parent's Name - Primary Contact: *
Your answer
Parent's Name - Secondary Contact:
Your answer
Home Address (this information is used for mailing next year's C.A.W. brochures): *
Your answer
Primary Parent Contact's Phone Numbers (please indicate work/cell/home): *
Your answer
Secondary Parent Contact's Phone Numbers (please indicate work/cell/home):
Your answer
Emergency Contacts - in case Parents can not be reached (Provide name & local phone number: *
Your answer
EMERGENCY MEDICAL TREATMENT - IF EMERGENCY treatment by a doctor or ambulance is needed AND WE CANNOT BE REACHED, we AUTHORIZE the Creative Arts Workshop to obtain any necessary treatment at our family's expense. *
Required
List any restrictions of activities or allergies (PLEASE TALK PERSONALLY TO THE C.A.W. DIRECTOR IF YOUR CHILD HAS SEVERE MEDICAL NEEDS (i.e. environmental, physical handicaps, etc.) SO WE CAN BETTER SERVE YOUR CHILD.
Your answer
Are tetanus, Hepatitis B & DPT shots up-to-date? *
Yes
No
N/A
Student #1
Student #2
Student #3
Student #4
AAUW, the Creative Arts Workshop (C.A.W.) and the Pleasant Valley School District (PVSD) assume no responsibility for children left unsupervised or unattended on the premises for the duration of this program. Parents must take care of their own children during class periods for which no enrollment has been made. Students may attend only those classes for which they have registered and for which fees have been paid. Fees are not transferable from one class to another. Parents will also be prompt in daily pick-up of children as scheduled. Failure to comply with the above may result in withdrawal of the student from the Creative Arts Workshop. *
Required
I, the undersigned, hereby release and discharge the American Association of University Women (AAUW), Camarillo Branch, Inc. and Creative Arts Workshop, its officers, employees, agents and servants from all liability arising out of or in connection with Creative Arts Workshop classes that result from any cause other than the negligence of AAUW Camarillo Branch, Inc. and Creative Arts Workshop. *
Type in full legal name, below. - This serves as your legal signature for the above statement.
Your answer
I am the parent/grandparent/legal guardian of this/these student(s). On behalf of my child (children), I consent to photographs and news media. I release C.A.W., AAUW, Camarillo Branch, the Director, staff and volunteers from all liabilities that may arise on account thereof. *
Required
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