Art Room After School for 5th-8th Graders : Unit 5
If you are registering multiple children, a separate form must be completed for EACH child
THURSDAYS 3:30 - 5:30 pm
May 2- June 4
Astoria Middle School
1100 Klaskanine Ave, Astoria, OR
Student Information
Student Name
*
First Name
Last Name
Student Grade
*
What school does the student attend?
*
Parent Information
Parent 1 Name
*
First Name
Last Name
Parent 1 Email
*
example@example.com
Parent 1 Phone
*
Please enter a valid phone number.
Parent 2 Name
First Name
Last Name
Parent 2 Email
example@example.com
Parent 2 Phone
Please enter a valid phone number.
Emergency Contact Information
Emergency contacts are trusted adults that should be contacted in the event we cannot reach a parent/guardian. Please list a different adult in the fields below than yourself or parent/guardian 2.
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Email Address
example@example.com
Do you give this emergency contact authorization to act on your behalf in a medical emergency involving your child when parent/guardian 1 and/or 2 cannot be reached?
*
Yes
No
Authorized Adults for Pickup
Please list the first AND last names of any other adults that have authorization to pick up the student from the program. *Adults can be added or removed from the list of authorized adults for pickup by emailing first AND last names to info@artroomastoria.org
Medical Information
Does the student have any allergies?
Does the student have any health conditions that Art Room staff should be aware?
I authorize staff of the Art Room after school program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility to secure necessary medical treatment for my child.
*
Yes
Informed Consent/General Release
My child has permission to participate in the activities of the Art Room After School program at Astoria Middle School. I agree to release Art Room and its representatives from any claim for personal injury or damages resulting from my child’s participation in the activities associated with the program. I understand the activities and give permission for my child’s participation. As the parent or legal guardian of the above named child, I am authorized to electronically sign this permission form. I HAVE READ AND UNDERSTAND THIS PERMISSION FORM AND UNDERSTAND THAT ART ROOM IS RELEASED FROM LIABILITY AS A RESULT OF ANY INJURY OR DAMAGES FROM MY CHILD’S PARTICIPATION IN THIS PROGRAM. I ALSO UNDERSTAND THAT IN THE EVENT OF EMERGENCY OR MEDICAL NEED, I HAVE GIVEN MY PERMISSION TO HAVE MY CHILD RECEIVE MEDICAL TREATMENT BY THE BEST MEANS AVAILABLE.
*
I consent
Photo Consent & Release
The children participating in Art Room events may be highlighted in efforts to promote Art Room programs and activities. For example, photos of participating children and parents may be featured on social media, flyers, or our website to increase public awareness of our organization in the community. Do you grant permission to Art Room to post my child’s photo on Art Room’s Instagram account, Facebook account, website (ArtRoomAstoria.org), and printed and digital publications for the purpose of promotion and increasing public awareness of the organization? I understand and agree that any photograph using my likeness will become property of Art Room and will not be returned. I acknowledge that since my participation with Art Room is voluntary, I will receive no financial compensation. I acknowledge that my child is under 18 years old and lacks the legal capacity to enter into binding agreements. I hereby give permission for images of my child, captured during Art Room programming through video, photo and digital camera, to be used solely for the purposes of Art Room online promotional material and digital and print publications, and waive any rights of compensation or ownership thereto.
*
I consent to the use of photo/video of my child for promotional purposes
I do not consent
Submit
Should be Empty: