One on One Consent Form

Student's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Home Number

Cell Number*

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number*

Alt. Phone Number

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Jenny T. during the selected workshop. In exchange for the acceptance of said child’s candidacy by Jenny T., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Jenny T. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Jenny T. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named participant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named participant. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Jenny T. and its affiliates including co teachers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered sessions.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

I consent to the use of photographs of my child participating in art activities for with Jenny T. on social media and promotional materials.

YESNO

Do you consent to your child participating in walking activities from 'Tis Annex or The Art Hive to various locations around Downtown Prescott, or nature journal in the Prescott National Forest?

YESNO

Are there any concerns or restrictions regarding your child's participation in walking activities?

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.

In consideration for allowing my child to participate in the walking activities described above, I hereby release, waive, discharge, and covenant not to sue the organizers, staff, or volunteers of the summer camp program for any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by my child while participating in such activities.

I understand that walking activities involve certain risks, including but not limited to trip hazards, uneven terrain, and encounters with vehicles or pedestrians, and I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, including death, that may be sustained by my child as a result of participating in such activities.

Date

Signature

One on One Art Lesson Consent Form

Student Information