2024Participant Consent Form

In-Person Participant Consent Form

2025
This form must be completed and on file in order to participate in Clallam Mosaic programs
Name of Participant*

First NameLast Name
Email*
example@example.com
I will participate in all Clallam Mosaic activities that I sign up for, unless otherwise noted in my registration.*

Agree
I will not attend class if I have fever, fatigue, difficulty in breathing, dry cough or any other symptoms relating to any communicable disease within 3 days of my attendance date (must be fever free for 24 hours); diarrhea; vomiting; pink eye and/or severe headache.*

Agree
My caregiver and/or I will manage all of my personal hygiene and toileting needs.*

Agree
In the event of an emergency wherein the named emergency contact(s) is not available, I give my consent to provide treatment and to conduct any tests essential to render necessary medical care.*

AgreeI will provide a written statement of emergency permission, protocols
I grant permission to Clallam Mosaic to use any photograph/video of me and my name for newspaper articles, news releases, publications (brochures, newsletters, websites, etc.), social media posts and community awareness programs.*

AgreeDisagree
I grant nonexclusive permission to Clallam Mosaic to reproduce, distribute, and modify the work I create during my participation in Clallam Mosaic classes. I grant permission to use the work for any purpose, including commercial purposes. I expect no compensation for the work or the permission being granted.*

AgreeDisagree
I agree to follow Mosaic’s “Code of Conduct”*

Agree
I agree that information on my registration forms can be shared with emergency personnel in case of an emergency.*

Agree
Signature

Clear
To complete registration, the following forms are needed:

Fill out once in 2025:
1. 2025 In-Person Intake Form
2. 2025 Health Status Form
3. 2025 Health Liability Release Waiver
4. 2025 In-Person Code of Conduct
5. 2025 Participant Consent Form
Fill out each term:
- The appropriate term's Registration Form
Should be Empty:

In-Person Participant Consent Form