Imagination Exploration: Registration Form for Youth Programs

Registration Form for Youth Programs
Youth Information
Student's Name*

First NameLast Name
Address*

Address

Street Address Line 2

City/Postal CodeState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Grade
School
Will your student need transportation from Clear Lake Elementary School? (If registering for Imagination Exploration only)

Yes, my student needs transportation from Clear Lake Elementary SchoolNo, my student will arrive at Imagination Exploration by other meansNo, I am registering for a different class that has no transportation option available at this time
List all allergies*
Please indicate if your student carries and EpiPen or inhaler*

YesNoOther
Please indicate health/behavior related information that will help us provide an optimal experience
Parent/Guardian Information
Parent's/Guardian's Name*
Phone*
E Mail*
example@example.com
Parent's/Guardian's Name
Phone
E Mail
example@example.com
Additional Address

Address

Street Address Line 2

CityState

Zip,
Please list any individuals that do NOT have permission to pick up this student:*
Please list any individuals that DO HAVE permission to pick up this student:*
Emergency Contact Information
Contact 1: First and Last Name*
Relationship to child*
Primary phone*
Secondary phone
Contact 2: First and Last Name*
Relationship to child*
Primary phone*
Secondary phone
Medical Information
Pediatrician or clinic name*
Phone*
Preferred hospital in event of emergency*
Insurance Company*
Policy Number*
Emergency Treatment Permission

In case of emergency and in the event that none of the emergency contacts can be reached, the Clear Lake Arts Center will need signed authorization (below) to seek medical assistance for your child.

I give permission to the Clear Lake Arts Center, its employees and designated representatives, to use whatever emergency (e.g., first aid, disaster evacuation) measures are judged necessary by them for the care and protection of my child while under supervision of the Clear Lake Arts Center. In case of medical emergency, I understand that my child will be transported to appropriate medical facilities by a local emergency unit for treatment if the local emergency resource (police or paramedics deems it necessary. It is understood that in some medical situations the staff will need to contact the local emergency resource before the parent, child's physician and/or other emergency contacts acting on the parents' behalf.
I agree with statement above*

YesNo
Emergency Treatment Permission

I request that the medications listed below be given as prescribed by my child's physician during the youth art sessions. I release the Clear Lake Arts Center personnel and teachers from any liability in relation to the administration of such medication. I understand that I must provide a physician's order for the administration.
I agree with statement above*

YesNo
Child's Prescribed Medications
Photo Release
In the event that students are included in any publicity or publications involving the Clear Lakes Arts Center, I give permission for my child to be photographed or video recorded and give Clear Lakes Arts Center the right to publish my child's photo (with first name only or no name) and/or written or ilustrated work in the Clear Lakes Arts Center website, catalog, other webpages, or publications in connection with Clear Lakes Arts Center Arts projects. I understand that my signature at the end of this form amounts to a waiver of any claim my child or might have against any individual(s) or the Clear Lakes Arts Center due to the release of this information.
I agree with statement above*

YesNo
I hereby acknowledge, understand, and agree that the Clear Lakes Arts Center, its directors, administrators, and employees shall not be responsible or liable for any damages of any type whatsoever, including personal injury and property loss arising from any activity or occurrence described in this form unless such damage or loss is the direct result of the willful or grossly negligent act of the Clear Lake Arts Center, its directors, administrators, or employees.

Signing below, I agree to accept the rules and regulations of the Clear Lake Arts Center set forth in the Health and Photo Release Form and that appear in the Youth Arts catalog or any other written or verbal communications from the Clear Lakes Arts Center. I further confirm that I have read and agree to be bound by the terms and conditions and agreements set forth herein.
Parent/Guardian Signature (Required)*

Clear
Date*

MonthDayYear
Date
RELEASE OF LIABILITY AND ASSUMPTION OF RISK
In consideration of receiving permission from The Clear Lake Arts Center (the "Art Center") to use any of its equipment or facilities or to engage or participate in or receive the benefit of any instruction or observation ("Activity") whether such Activity is organized by the Art Center or not, the undersigned User, for myself, my personal representatives, my heirs, and assigns, acknowledges that l understand the nature of such Activity and that I am qualified in good health, and in proper physical condition to participate in the Activity.

I fully understand that the Activity may involve risks and dangers of bodily injury, whether caused by my own actions, the actions of others, the conditions in which the Activity takes place, or the negligence, action or inaction of the Releasees named below. I further understand that in the event of injury, all losses, costs, damagesor expenses incurred by me therein must be paid by me or my personal insurance company.

With this knowledge, I hereby release, discharge and hold harmless the Art Center, its directors, officers, employees, agents, volunteers, other participants and all others (the "Releasees") from any and all claims or causes of action, both known and unknown, arising out of any negligence, omission, action or inaction, including negligent rescue operations: and I further agree to indemnify and hold harmless each of the Releasees from any loss, liability, damages, costs or expenses which they or may incur as the result of or in connection with such claim.

By signing below. I indicate that have read this agreement, fully understand its terms, and understand that have given up substantial rights by signing it; that hove signed it freely; and that I intend if to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that should any portion of this agreement be held invalid, the balance shall continue to be in full force and effect.

If the Participant is a minor, this agreement has been signed by the Parent or Legal Guardian, who represents that they have the ability to give this waiver on behalf of the minor child, and that the child meets the physical requirements of the Activity.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
If signing for a minor, print name/s*
Payment

Select up to 8 weeks of Imagination Exploration to register your student for. To register for more than 8 dates, you will need to fill out another form to ensure our Health & Safety Form is up-to-date for your student's safety.

Imagination Exploration*

Imagination ExplorationThis after school program invites students of all ages to attend Imagination Exploration. We will explore the arts from different angles and participants will be encouraged to create in a guided, open studio format. Imagination Exploration will take place from 2:30pm - 4:30 pm on Wednesday afternoons for students of all ages. Transportation via buses to the Clear Lake Arts Center is available for Clear Lake Elementary School students. The cost is $10 per week with scholarships available.Advance registration through CLAC is required.

$10.00