Roaring Mouse Medical Information & Release Form Logo

  • Roaring Mouse Medical Information & Release Forms

    Thank you for registering your child(ren) for an upcoming class or camp at Roaring Mouse! This electronic form must be completed once per school year and any time pertinent information changes. If you have more than one child, you may list each child's information below. Please contact director@roaringmouse.org if you have any questions.

  • Student 1 Information

    If registering more than one student, please include the second student's information in the Student 2 section.

  • Student 1 Allergies

  • Epi-pen Permission Download

    If STUDENT 1 will be bringing an epi-pen to Roaring Mouse, please download our Allergy and Anaphylaxis Emergency Form HERE to complete prior to class/camp. You may email the signed form to us or bring it with you on the first day of class.

    Note: we require a doctor's signature on this form.

  • Student 1 Health Info

  • Medication Authorization Download

    If STUDENT 1 will be bringing medication to Roaring Mouse, please download our Medication Authorization Form HERE to complete prior to class/camp. You may email the signed form to us or bring it with you on the first day of class.

    Note: we require a doctor's signature on this form.

  • Student 1 Vaccinations/Immunizations

  • *Note: Students who have not been vaccinated may be excluded from participation if an outbreak of a disease occurs that they have not been fully immunized against, for the duration of the outbreak. 

  • Student 1 Potty Readiness

    Complete this section if your child is 4 years old or younger AND wears pull-ups, or needs help with the potty.

  • SKIP THIS SECTION IF ONLY REGISTERING ONE STUDENT.

  • Student 2 Information

    Complete this section if registering a sibling or if you would like us to have a sibling's info on file for a future class.

  • Student 2 Allergies

  • Epi-pen Permission Download

    If STUDENT 2 will be bringing an epi-pen to Roaring Mouse, please download our Allergy and Anaphylaxis Emergency Form HERE to complete prior to class/camp. You may email the signed form to us or bring it with you on the first day of class.

    Note: we require a doctor's signature on this form.

  • Student 2 Health Info

  • Medication Authorization Download

    If STUDENT 2 will be bringing medication to Roaring Mouse, please download our Medication Authorization Form HERE to complete prior to class/camp. You may email the signed form to us or bring it with you on the first day of class.

    Note: we require a doctor's signature on this form.

  • Student 2 Vaccinations/Immunizations

  • *Note: Students who have not been vaccinated may be excluded from participation if an outbreak of a disease occurs that they have not been fully immunized against, for the duration of the outbreak. 

  • Student 2 Potty Readiness

    Complete this section if your child is 4 years old or younger AND wears pull-ups, or needs help with the potty.

  • Parent/Guardian Information

  • Waivers and Agreement

  • These items apply to all students listed on this form.

    BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

  • Photo Release

    I grant Roaring Mouse Creative Arts Studio, LLC, permission to use photographs of and artwork by my child(ren) to promote the mission and programs of Roaring Mouse Creative Arts Studio in both print and electronic media, including social media. I authorize Roaring Mouse Creative Arts Studio, LLC, its assignees, and transferees, to copyright, use and publish the same in print and/or electronically for any lawful purpose, including for such purposes as publicity, illustration, advertising, and Web content.

  • Hold Harmless

    I understand that Roaring Mouse Creative Arts Studio, LLC, will make every effort to keep my child(ren) safe and free from harm.  I agree for my child(ren) to receive instruction and to participate in the Roaring Mouse Creative Arts classes.  For and in consideration of my child(ren)'s instruction and participation, I hereby release and hold harmless Roaring Mouse Creative Arts Studio, LLC, its owners, agents and instructors from all claims and liability arising from my child(ren)'s instruction and participation in the Roaring Mouse Creative Arts classes.

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  • Medical Release and Authorization

    As Parent and/or Guardian of the named child(ren), I give my consent for emergency medical and surgical treatment of the named child(ren) in the event that such treatment becomes necessary. I grant my permission for treatment in a licensed hospital by a licensed physician and the physician’s assistants and designees, including such hospital personnel as the physician may deem necessary. I understand that hospital personnel will make reasonable attempts to contact me before initiating treatment. I am aware that the practice of medicine is not an exact science and that no guarantees can be made concerning the results of treatment. The child(ren) named in this consent form may receive all treatment provided according to generally accepted standards of medical practice.

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