Level Up Life skills

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Level Up Life Skills Registration Form

Thank you for registering for our life skills groups! We request that you read and complete this form in its entirety in order to be registered. If you have any questions please call the office at 860-284-9779 or email sarah@creativedevelopmentct.com
Teen's Information
Teen's Name

First NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian #1

First NameLast Name
E-mail
example@example.com
Phone Number
Address if different than Teen

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian #2

First NameLast Name
Phone Number
E-mail
example@example.com
Address if different than teen's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Registering a sibling

YesNo
Use promo code CDSIB10 for a sibling discount
Please type sibling's first name, last name, and date of birth

Please select which program you would like to register this participant for

Job Readiness & Self-Confidence14+ yrs Tuesday 12/27 1-3pm

$49.00 Quantity

Kitchen Safety and Cooking14+ yrs Wednesday 12/2 1-3pm

$49.00 Quantity

Health and Wellness14+ yrs Thursday 12/29 1-3pm

$49.00 Quantity

Enter coupon

Total

$0.00

Does your teen have any allergies or diet restrictions? If yes, please describe.
Does your teen have any medical conditions or diagnoses? If yes, please describe.
Informed Consent and Acknowledgement

I, hereby give my understanding and give approval for my child to participate in any programs offered with Creative Development, LLC and CREATE Independence, INC. I acknowledge that there are certain inherent risks, dangers and hazards (foreseen and unforeseen) inherent in attending and participating in Creative Development, LLC and CREATE Independence, INC Enrichment programs, including but not limited to risks related to use of equipment and facilities, personal safety and risks of property damage.

In recognition of the risks, dangers and hazards (foreseen and foreseen) with attending and participating in said program(s), the undersigned confirms the participant is capable of attending and participating in said program(s) and activities. The participant is willingly and voluntarily attending and participating and the undersigned agrees that they and the participant shall assume all risks, dangers and hazards (foreseen and unforeseen) inherent in, arising from or related to the participant’s attendance and participation in the Creative Development, LLC and CREATE Independence, INC Enrichment Program.

I hereby authorize the Creative Development, LLC and CREATE Independence, INC staff to obtain or provide medical treatment for my child for such injury or illness during program offerings. I hereby hold the staff at Creative Development, LLC and CREATE Independence, INC and Creative Development, LLC and Creative Development, LLC/ CREATE Independence, INC harmless in the exercise of this authority.
Signature*

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Media Use Consent and Release

As the parent and/or legal guardian of the child listed, I hereby give consent to Creative Development, LLC and CREATE Independence, INC to use photograph(s) or other electronic media of myself/client (hereafter “Images”) for any business purpose, including but not limited to, use in print, publications, periodicals, books, brochures, video and/or audio productions, advertising and/or promotional materials, social media platforms, websites, Instagram, Facebook, or any other media. My child's name will not be used on any media used or shared.

By my signature below, I hereby release Creative Development, LLC and CREATE Independence, INC and its owners, directors, managers, employees, and contractors, from any and all liability that may arise in connection with the Images. This release shall be binding upon my heirs, next of kin, executors, and administrators.

I understand that I may revoke this authorization and terminate further use of the images at any time by providing written notification to Creative Development, LLC and CREATE Independence, INC. I understand that my revocation will not affect any actions taken prior to Creative Development, LLC and CREATE Independence, INC’s receipt of written notification of termination.

I am the parent or legal guardian of the named child and have the legal
authority to execute this consent and release.
*

I give permission for Creative Development, LLC and CREATE Independence, INC to use photograph(s) or other electronic media of my child. I understand my child's name will not be used.I do not give permission for Creative Development, LLC and CREATE Independence, INC to use photograph(s) or other electronic media of my child.
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.
How did you find out about our programs ?*
Were you referred by another person or family? If yes, please list who.

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.

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Level Up Life Skills Registration Form

Teen's Information

Parent/Guardian Information

Use promo code CDSIB10 for a sibling discount