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Art Rocks Teens (A.R.T.) Parental Permission Form |
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You may print this form, fill it out and mail it to or drop it off at Arts Center, attn: Art Rocks Teens. Remember to include a copy of the Registration Form.
Student Name: ___________________________________________ Age: _____ Grade ____
Address: _________________________________________________________________
Phone: ____________________________ Email:_____________________________________
Father (or guardian): ________________________ Phone (h) __________ (w) __________
Mother (or guardian): ________________________ Phone (h) __________ (w) __________
Address (if different from above): _________________________________________________
Physician’s Name: _____________________________ Phone: __________________________
Hospital ___________________________________
In case of emergency please notify: _____________________________________________
Relationship to teen: _____________________ Phone (h): ____________ (w):____________
Please list any allergies or food limitations: ________________________________________
Please list any medical conditions or limitations we should be aware of: ___________________
________________________________________________________________________________________________________
Other special considerations or concerns: ____________________________________________
The Arts Council of Pendleton (ACP) has permission to use my child’s name and picture for any media purpose (circle one) YES NO
I give permission for the ACP staff, instructors or volunteers to seek emergency medical assistance in the event that they are unable to reach me (circle one): YES NO
I give permission for my child to leave the building on walking field trips (circle one): YES NO
The following persons ONLY have permission to pick up my teen: ________________________
_____________________________________________________________________________
My child has permission to walk home (circle one) YES NO
Informed Participant Consent
I, the parent or guardian of the above named participant, understand the possibility of injuries resulting from the activities sponsored by the ACP. I hereby acknowledge and accept all risks and hazards incidental to participation in such activities. I hereby release, absolve, indemnify, and hold harmless the ACP, its employees and agents from any liability for injury whether to person or property of the participant. In case of personal injury to participant, I hereby waive any and all claims against the ACP, its employees and agents.
Parent or guardian name (please print): _________________________________________
Signed: _____________________________________ Date: _________________________
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