C.A.E. Adult Enrollment Packet

C.A.E. Adult Participant Registration

Upon completion, a C.A.E. representative will contact you within 1-2 business days.
Registration Type*
Date*

MonthDayYear
Date
What is the name of the program you are registering for?
Name*

First NameLast NameSuffix
City You Live In*
Other - City You Live In
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Gender*
Date of Birth*

MonthDayYear
Date
Ethnicity*
Select all that applies
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
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 AuthorizeI 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 AuthorizeI 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 ConsentI DO NOT Consent
e-SIGNATURE
e-Signature Statement*

I certify that all the information I have given is true and accurate to the best of my knowledge and belief.
e-Signature *
Whether digital or encrypted, the electronic signature isintended to authenticate this document and have the same force and effect as amanual signature.
Please verify that you are human*
Should be Empty:

C.A.E. Adult Participant Registration