Circle Round The Square 2025 Summer Program

Circle Round The Square 2025 Summer Program

Submit One Form Per Child
My child will be able to attend classes all days: July 7 - July 18, 9 a.m. – 4 p.m.*

YesNo
(If you answered NO, please fill in when they will miss and why)
My child will need bussing to Hocking College every day:*

YesNo
CAMPER INFO
Child's Name*

First NameLast Name
Grade entering next year (only children entering grade 6 or above next year)*
grade entering next year
Date of Birth*

MonthDayYear
Date of Birth
GUARDIAN INFO
Parent/Guardian’s name(s)*
Home Address (for bus pick up)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address (if different for mailing)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Which of these phone numbers can be texted

HomeCellWork
Email Address
used for contact about camp info
Please rank the order (1st, 2nd, and 3rd) of your preferred communication method
Phone Call Text Email
Emergency Contact
Emergency Contact Name: First Name Last Name
Emergency Contact Relation: Relation
Emergency Contact Phone: Area Code Phone Number
By signing this form you are agreeing to: allow your child to participate in the program; allow participation in program research and use data in reports; release Circle Round theSquare, its artists, staff and Hocking College from any and all liabilities incurred during participation and; give us permission to use your child’s photograph or images of their work, or video shots or photos on the website and in promotional, grant and sales materials, and to be published in a book.*

I Agree
Please list all medications taken, allergies, medical conditions or specialneeds:
In case of accident or serious illness, I request that I/we be contacted. I givepermission for emergency medical treatment and to be transferred to thenearest medical facility. I agree to assume all costs related to such treatmentand I release Circle Round the Square and Hocking College from anyresponsibility for injury or illness that may occur while my child participates.*

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Date of signing

MonthDayYear
Date
A COMPLETED FORM IS A REQUEST FOR YOUR CHILD TO BE ENROLLED IN
CIRCLE ROUND THE SQUARE. ONCE ENROLLED, A LETTER VIA MAIL OR
EMAIL WILL ARRIVE WITH INSTRUCTIONS AND THE BUS SCHEDULE (IF
REQUESTED) BY THE FIRST WEEK OF JULY! ALL DATES ARE SUBJECT TO
CHANGE BUT YOU WILL BE NOTIFIED IF THIS IS THE CASE.

CONTACTS
Josh Birnbaum, Program Director
director.circleroundthesquare@gmail.com
310-991-5648
Kaila Rife, Operations Director
Operations.circleroundthesquare@gmail.com
740-590-3868

Release and Waiver of Liability and Indemnity Agreement
In consideration of being permitted to enter the Hocking College Student Center for any purpose,including, but not limited to: observation, use of facilities or equipment, or participation in anyway, the undersigned, for him/herself and any personal representatives, heirs, and next of kin hereby acknowledges, agrees, and represents that he or she has, or immediately upon entering, will inspect such premises and facilities. It is further warranted that such entry into the HockingCollege Student Center for observation, participation or use of any facilities or equipment constitutes an acknowledgement that such premises and all facilities and equipment thereon have been inspected and that the undersigned finds and accepts same as being safe and reasonably suited for the purposed of such observation or use.I understand that I am about to participate in an experience that may require a member of theHocking College Student Center staff to provide transportation.THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES, AND COVENANTS NOT TO BRING LEGAL ACTION AGAINST The Hocking College StudentCenter or Hocking College, its President, Trustees, employees, agents or assigns (herein after referred to as “releases”) from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releases or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein.THE UNDERSIGNED HEREBY AGREES TO INDEMINIFY AND SAVE AND HOLD HARMLESS the releases and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about the Hocking College StudentCenter and/or while using the premises or any facilities or equipment hereon.THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER, AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Ohio and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, AND FURTHER AGREES THAT NO ORAL REPRESENTATION, STATEMENT, OR INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE.I HAVE READ THIS RELEASE IN ITS ENTIRETY AND ALL INFORMATION WITHIN IS TRUTHFUL AND ACCURATE TO THE BEST OF MY KNOWLEDGE.*

I Agree
Students Name*

First NameLast Name
Grade entering next year *
grade entering next year
Date of signing

MonthDayYear
Date
Signature of Parent/Guardian/18 year old Student**

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*All applicants over age 18 must sign; one parent/guardian signature applies to all applicants under age 18.

CIRCLE ROUND THE SQUARE 2025 SUMMER ARTS PROGRAM

Camera Agreement
You are being given photography equipment that all the kids in the summer program will share. It is essential that you take care of it. In order to participate in this summer’s photography classes, you must sign this agreement signifying the following: 1. You will receive a camera from your instructor during photo class. 2. You will take good care of the camera as instructed in class. 3. You will return the camera in working condition at the end of the class. You will be granted a camera and will be responsible for it. Any damage or loss incurred will require you the replace the materials. We will report missing cameras or other equipment to the local police.*

I Agree
Child's first and last name*

First NameLast Name
Parent/Guardian's name*

First NameLast Name
Parent/Guardian signature*

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Date of signing

MonthDayYear
Date
Should be Empty:

Circle Round The Square 2025 Summer Program

CAMPER INFO

GUARDIAN INFO

Emergency Contact

Release and Waiver of Liability and Indemnity Agreement

CIRCLE ROUND THE SQUARE 2025 SUMMER ARTS PROGRAM