Youth Workshop Registration Form

Student Information

Student's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Cell Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

Does the student intend to attend all 4 workshops from 10am to noon on Sept. 24th, Oct. 1st, Oct. 8th, Oct. 15th and the showcase from 6-8pm Oct. 22nd, 2022?

This is a free workshop offered to youth grades 6-12. We will not require payment to attend. We do have operational expenses to pay teaching artists and buy supplies and snacks. Would you be willing to sponsor your student for $25 or another amount? If yes, please visit livingspiritumc.org/give and select Youth Arts Workshops in the dropdown.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by {B-Girl Media, Living Spirit UMC and Lake Harriet UMC} during the selected workshops. In exchange for the acceptance of said child’s candidacy by {B-Girl Media, Living Spirit UMC and Lake Harriet UMC}, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless {B-Girl Media, Living Spirit UMC and Lake Harriet UMC}. and all its respective affiliates, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected workshop and showcase sessions. In case of injury to said child, I hereby waive all claims against {B-Girl Media, Living Spirit UMC and Lake Harriet UMC}, including all instructors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all physical activities, including dance, drumming and performing. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Photo and Video Release and Authorization As Parent and/or Guardian of the named student, I hereby authorize the photo and video documentation of the workshops by B-Girl Media, Living Spirit UMC and Lake Harriet UMC for the use as educational, archival and promotional. I understand that photos may be taken, videos may be taken, the program may be broadcast via zoom, that zoom attendees may be broadcast to the venue in front of a live workshop or performance, and that my student's work and likeness may be shown or appear in a performance setting or displayed in a gallery setting, online or in person. I agree to all of the uses described above.

Confirmation 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.