YOUTH CREATIVE COLLECTIVE AFTER SCHOOL WORKSHOP 2023

Youth Creative Collective After-School Artistic Expression Workshop 2023

Registration Form; Medical, Contact and Authorized Pick Up Information
PERSONAL INFO
Participant Name*

First Name Last Name
Age of as of 1/10/2023*
Birth Date*
example: 05/06/2006
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Name*

First Name Last Name
Parent/Guardian Phone Number*

Area Code Phone Number
Parent/Guardian Email*
example@example.com
Emergency Contact (if Parent/Guardian can't be reached)*

First Name Last Name
Emergency Contact Phone Number*

Area Code Phone Number
Emergency Contact's relationship to the participant*
Authorized Pickup Person(s)

Please list the names of those you authorize to pick up your child in the event you are not available to do so.
Pick-up Person Name*

First Name Last Name
Pick-up Person Phone Number*

Area Code Phone Number
Pick-up Person relationship to the participant*
Secondary Pick-up Person Name*

First Name Last Name
Secondary Pick-up Person Phone Number*

Area Code Phone Number
Medical Information
Snacks will be served to the participating children. Does your child have any food allergies? If so, to what? If none, please respond NA.*
Please shortly list any of the following concerning your participating child: current medications, allergy medications or chronic health concerns. If none, please respond NA.*
Are there any special needs that your participating child has that we should know about to best facilitate your child's success and development? If so, please share that information here. If not, please respond NA.*
Physician Name

First Name Last Name
Physician Phone Number

Area Code Phone Number
Information Release

Please read the following and sign if you agree to ALL statements
LIABILITY RELEASE

I give permission for my child to participate in Youth Creative Collective at The Dream Center. While most activities will be arts-based and indoors, one of the activities will include my child traveling, accompanied by the adult staff of Youth Creative Collective, to nearby playgrounds on warm, weather days and I give consent. I understand that participation in these activities requires participants to abide by applicable rules and standards of conduct. I hereby release The Dream Center staff and volunteers from responsibility and liability for any illness or injury that my child may sustain during this program. In the event of an emergency, I hereby authorize an adult leader of this program, as an agent for me, to consent to medical attention from a licensed medical professional. I expect to be contacted as soon as possible. I agree not to bring my child to any sessions of Youth Creative Collective if my child is ill.

MEDIA RELEASE

I also give The Dream Center permission to publish in print, electronic or video format the likeness or image of my child and/or audio recording of my child. I release all claims against The Dream Center with respect to copyright ownership and publication including any claim for compensation related to the use of materials. Images, video or audio recordings of my child taken or recorded by The Dream Center can be used in print, broadcasting or other forms of marketing and advertising: brochures, newsletters, reports, online (website, Twitter, Facebook, Instagram, YouTube). These photos, videos or other images of recordings may be used by The Dream Center without payment of fees, royalties or other remuneration.
Parent Signature

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Should be Empty:

Youth Creative Collective After-School Artistic Expression Workshop 2023

PERSONAL INFO

Authorized Pickup Person(s)

Medical Information

Information Release