2023-2024 Cedar Grove Liber Academy Medical and Media Release Forms and Agreements

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Fill out these forms yourself and for all children you will have with you attending classes to completely register. Thank you!

Email *

Family Last Name (s) *

Name of Parent Attending Each Week *

Spouses Last Name *

Spouses First Name *

Address *

Best Phone number *

Alternate Phone Number *

Usable Gmail account to connect on SLACK (make a new one if you need to please. Thank you!) *

Cedar Grove Liber Academy chooses to operate under the present Constitution (Based on ALTUS's Family Liber Academy constitution form) while we work toward ratification. All participant and member families need to read the Working Constitution and agree to abide by the principles and policies contained therein. The Governing Board to supply access to a copy of the current constitution. *

***I acknowledge that checking this box and writing my full name in the box at the end of this section serves as my signature.***

Required

In case of emergency notify:
*

Emergency Contact Phone Number *

Name of Doctor *

Phone Number Doctor *

Health Insurance and ID number *

Permission for Treatment and Discharge: My permission is granted for Cedar Grove board members, mentors, teachers, or parents to obtain necessary medical attention in case of sickness or injury for myself. I do hereby release, and forever discharge all sponsors and Cedar Grove (board members, mentors, teachers, or parents) from any and all claims, demands, actions or cause of action, past, present, or future arising out of any damage or inquiry while participating in classes, school activities, or field trips, or providing emergency medical attention to myself.
*

***I acknowledge that checking this box and writing my full name in the box at the end of this section serves as my signature.***

Photo release: I hereby release photos taken of myself during Cedar Grove classes, events, and activities to be used on the Cedar Grove website and social media accounts.
*

***Yes, I release photos of myself to be used. I acknowledge that checking this box and writing my full name in the box at the end of this section serves as my signature.***

***No, I do not release photos of myself to be used. I acknowledge that checking this box and writing my full name in the box at the end of this section serves as my signature.***

Type full name for signature
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