Bindlestiff's Summer Cirkus STILTS 2021
REGISTRATION - SUMMER CIRKUS WEEK AT HUDSON YOUTH CENTER for age 12 and up
Email *
Child's Name First, Last *
Child's Date of Birth: mm/dd/yyyy *
Parent / Guardian Name *
Address *
Phone *
Emergency Contact Name *
Emergency Contact Phone *
PERMISSION NOTICES
THERE ARE FOUR SEPARATE PERMISSIONS. PLEASE COMPLETE ALL FOUR.
PERMISSION NOTICE 1: I understand that participation in this activity involves a certain degree of risk. I have carefully considered the risk involved and have given my consent for my child’s participation. *
Required
PERMISSION NOTICE 2: I also understand that Bindlestiff will document classes for grant recording, archival, and promotional purposes, using photo, video, or audio recording and understand that this may include likenesses of my child. *
Required
PERMISSION NOTICE 3: I grant permission for the Bindlestiff Family Cirkus to use photo, audio, or video recordings of my child in appropriate and safe social media platforms to document and share program activities in non-commercial use. *
Required
PERMISSION NOTICE 4: By signing this form, I declare that I am the legal parent/guardian of the minor child listed above and authorized to grant such permission. Please type your first and last name here. *
Today's Date: *
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