Summer Ink Registration

Medical/Emergency Information
Please describe any special learning concerns you might have for your child:
Please describe any medical or health concerns (i.e. allergies, asthma, diabetes, etc.):
In the event that the individual(s) listed above cannot be reached in an emergency, I hereby give my consent for emergency medical treatment by a licensed professional and the transfer of my child to a local hospital.*

YesNo
Pickup Information
Does your child have permission to leave on their own (walk, bike, drive, etc.) at the conclusion of the program?*

YesNo
If anyone other than the parents/guardians listed above will be picking up your child, please enter their full names and phone numbers below:
Liability Release: I understand and agree that Lake Erie Ink: A Writing Space for Youth (hereafter “LEI”) is not responsible for supervising my child or for my child’s safety after the end of the program, and that neither LEI nor any of its staff members is liable for any physical or emotional harm to my child, caused by my child’s negligence or by the negligence, intentional act or criminal act of a third party, nor for any property or damage or loss caused by my child.*

YesNo

Permissions
I give permission to Lake Erie Ink to photograph/videotape my child while participating in program activities. These photos or videos may be used to promote Lake Erie Ink programs.*

YesNo
I give permission for Lake Erie Ink: a writing space for youth to publish my student’s work in any Lake Erie Ink publication, including our student anthologies, website, social media, blog, vlog, or podcast, using my first name, last initial, and age/grade.*

YesNo
Field Trip Permission

During programs, we may want to take your child outside on a walking field trip or to a local site for writing inspiration. Parents will be notified in advance of any off-site travel scheduled during camp.
I grant permission for my child to travel with staff and volunteers of Lake Erie Ink. (Select all. If all of the following boxes are not checked, you may be responsible for transporting your child to any fieldtrip locations.)

On footOn public transportation (bus or rapid transit)
Please sign below to verify the information provided is accurate.*

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Register for Summer Ink 2023!

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