C.A.E. Adult Student Registration

Name *

Prefix First Name Last Name Suffix

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Gender *

Date of Birth *

Date

Ethnicity

Select all that applies

Emergency Contact Information

Name

First Name Last Name

Phone Number

Please enter a valid phone number.

Name

First Name Last Name

Phone Number

Please enter a valid phone number.

Health History

All information contained will be kept confidential in accordance with The Health Insurance Portability and Accountability Act (HIPAA) of 1996

Have you been tested for COVID-19?

Have you been diagnosed with any serious illness? (i.e. severe asthma, heart disease, diabetes, depression)?

If yes, please list

Do you have any physical limitations which might present a special problem, such as any health factor which may require you to follow a limited program of activities?

If yes, please list

This health history is correct to the best of my knowledge

I Agree

e-Signature

Whether digital or encrypted, the electronic signature is intended to authenticate this document and have the same force and effect as a manual signature.

Blanket Release Attestation

MEDICAL RELEASE: In the event of an emergency, Community Arts Experience has my permission to contact the local emergency ambulance service, who will proceed as necessary. In case of serious injury or illness, my child can be transported to the nearest Emergency Room where they may proceed with treatment including but not limited to medications, injections, anesthesia, and surgery. *

I Authorize I DO NOT Authorize

FOR EMERGENCY TREATMENT: I authorize Community Arts Experience to arrange for transportation in case of an accident or acute illness of the participant. In the event it is not possible to receive instruction for the participant’s care, consent is given to any licensed physician for treatment. I allow the physician to administer medication and to perform necessary treatment for the preservation of the participant’s health and well-being. I understand that any cost incurred for the treatment of sudden illness or accident shall be paid by me. This authorization and consent for treatment are given to Community Arts Experience in conjunction with any authorized event. *

I Authorize I DO NOT Authorize

GENERAL RELEASE OF LIABILITY: In consideration of being allowed participant privileges in any program of Community Arts Experience, I hereby assume full responsibility for any risk of bodily injury, death, or property damage and/or while using the premises or any facilities or equipment hereon. I further agree to hold harmless Community Arts Experience, their partners, directors, officers, employees, agents, and volunteers from any and all claims that may result from any action for damages, including but not limited, to such claims that may result from injury or death, accident or otherwise, during or arising in any way from said activity. I acknowledge that this General Release of Liability of Community Arts Experience, partners,directors, officers,employees, agents, and volunteers is binding on me and not my heirs, personal representatives, successors, and assigns. *

I Acknowledge

MEDIA RELEASE: I hereby consent to the use of my name, likeness, and speech in an audiotape, videotape, internet, film or photograph made in any Community Arts Experience program activity for the business or publicity purposes of the Community Arts Experience program and its partners. I understand that any participation offers no remuneration and that my name, likeness, and speech may be edited, produced, recorded for duplication and distribution throughout the United States and abroad.I expressly release Community Arts Experience, its licensees, assignee's, affiliates and successors from any privacy, defamation, or other claims have arising out of the broadcast,exhibition, publication, or promotion of this program. *

I Consent I DO NOT Consent

Student Enrollment Payment

A one-time $75.00 annual enrollment fee is to be paid before class begins. No additional fees will be charged for any *eligible participant; unless specified otherwise (program/project activity supply expenses, field trips, etc.).

Adult Student Enrollment Fee

USD

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.