Workshop Houston Enrollment Form
Student First Name *
Your answer
Student Last Name *
Your answer
Gender *
Date of Birth *
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Student's School *
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Student Email
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Student Cell Phone #
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Parent/Guardian's Name *
Your answer
Relation to Student
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Parent/Guardian Phone # *
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Parent/Guardian Email *
Your answer
Street Address *
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City *
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Zip Code *
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Emergency Contact Name *
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Relation to student *
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Emergency Contact Phone # *
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Does your child have any allergies or medical conditions we should be aware of? If so, please list:
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I, the parent/guardian, give my permission for my child to participate in Workshop Houston’s After School/Summer Program. I agree to allow my child to use any and all hand and power tools, equipment or chemicals associated with these programs and realize that these and other associated activities may potentially cause injury. I understand that Workshop Houston is a neighborhood recreation program, not a licensed childcare facility.I also understand and agree to allow my child to participate in any field trips. I understand that I will be responsible for arranging transportation for my child to and from Workshop Houston. I give permission for Workshop Houston staff members to provide transportation for my child to and from field trips, as well as to and from Workshop Houston, if necessary. Additionally, Workshop Houston (WSH) employees may occasionally take photographs or videos for various purposes including our newsletter, our brochures, our website, outside media, and other forms of documentation. I give my permission for my child’s picture to be used for these purposes. I, the undersigned, agree to waive, release and relinquish any and all claims, losses, liabilities, suits, obligations,damages, judgments, actions, causes of action, and claims for costs and expenses, including, without limitation,attorneys’ fees (collectively, “Claims”), against Workshop Houston and Workshop Houston’s officers, directors, board members, employees and agents relating to or arising in connection with the participation of the minor named above in Workshop Houston events. If I have complaints or concerns regarding my child’s participation at Workshop Houston, I may obtain a complaint slip from Workshop Houston which will then review my concern and arrange a meeting with me to resolve the issue.
By entering my name below, I agree that (a) this application is an electronic record executed using my electronic signature (b) I am 18 or older and that I am able to contract for the minor as a parent/guardian and (c) I have read the above statement, fully understand its contents, and agree to all of its terms. *
Enter your full name below:
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I understand that Workshop Houston may have licensed counselors, and or counseling practitioners under supervision of a licensed counselor present at many Workshop Houston programs. These counseling professionals are present to help students develop appropriate social interactions and to learn to handle conflicts and emotions in a positive manner. I consent for my child to take part in interventions and learning opportunities with these professionals. I understand that one on one, in depth counseling will not occur without my notification and further consent.Parent/Guardian Initials: *
Enter Initials:
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