Art Camp 2022 13-17 year olds
June 20-14 2022 1-3:00 pm $225.00 per student
Student’s Name
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First Name
Last Name
Name of School
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Grade
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Student’s E-mail Address
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example@example.com
Birthdate
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Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Name
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First Name
Last Name
Parent Email
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example@example.com
Parent Cell Phone Number
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Please enter a valid phone number.
Emergency Contact’s Name
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First Name
Last Name
Relationship
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Mother
Father
Grandparent
Aunt or Uncle
Neighbor
Other
Emergency Contact Phone Number
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Please enter a valid phone number.
Does the student have any medical or allergy conditions?
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Adults authorized to pickup or drop off the student. Please include their phone number
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I give Permission for my student’s picture to be used on the Dallimonti Pottery Website
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Yes
No
Medical Release and Authorization: As Parent and/or Guardian of the named student, 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 athlete. 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 Dallimonti Pottery, and its affiliates including leaders, and Team helpers 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 session. 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.
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I Agree
Informed Consent and Acknowledgement: I hereby give my approval for my child’s participation in any and all activities prepared during the selected camp. In exchange for the acceptance of said child’s candidacy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Dallimonti Pottery, 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 Dallimonti Pottery, including all volunteers, helpers, affiliates, all participants, and, if applicable, owners and lessors of premises used to conduct the event. *
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I Agree
Confirmation: BY ACKNOWLEDGING AND SUBMITTING 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. *
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Yes
Electronic Signature
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First Name
Last Name
Date
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Month
-
Day
Year
Date
Submit
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