Art with HEART Registration Form
Child's Name *
Your answer
Age *
Your answer
Gender
Your answer
Birthday *
MM
/
DD
/
YYYY
Allergies *
Your answer
Parent/Guardian Name *
Your answer
Cell Phone *
Your answer
Home Phone
Your answer
Address
Your answer
Email Address
Your answer
Do you wish to receive email notifications from Art with Heart?
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
I hereby authorize Art with Heart to take photographs of my child named in this application during program activities, and to display and otherwise use these photographs without charge solely for the purpose of promotional material. *
Required
Consent Agreement- I hereby agree that Nicole Campbell-Schram, her staff and agents shall not be held liable for any injury, loss or damage to my child or my child's property, including deterioration of health. I understand that all registrants are expected to participate in all activities each day they attend classes. If my child has a temporary restriction (i.e: flu, allergy) I agree to inform the program contact person in advance of the daily activities. Every effort will be made to contact parents and/or guardians when an injury has occurred. Art with Heart may decline a participant due to physical and or/verbal abuse towards staff and other participants. In the case of any bullying situations, parents or guardians of all parties involved will be notified. I declare having read and understood the above informed consent agreement in its entirety and hereby give my consent for the registrant to participate knowing all of the foregoing. *
Required
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