Participant Information

Name*

First NameLast Name

Birth Date*

MonthDayYear

Last Grade Completed*

Gender*

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Hometown

Fine Art Talent:*

Program

Instrument

Skill Level

One star being a beginner. Five stars being advanced.

Parent/Guardian Information

Name*

First NameLast Name

Relationship*

E-mail*

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Participations, Release, and Medical Agreement

While we make every effort to provide a safe and pleasant environment for every person who attends our activities, we do require that this participation agreement be read, filled out, signed, and dated by all attendees (or their parent/guardian if under the age of 18) who wish to participate in activities with Sentito Arts Foundation.

With full knowledge, I accept full responsibility for any injury or accident that may occur to myself, my spouse, or my child while participating in Sentito Arts Foundation activities. I give permission for my child to participate in activities that occur on the grounds. These activities may include, but are not limited to, physical ice breaker games, indoor/outdoor activities involving props, stage rehearsal with lighting and strenuous competition games.

Although Sentito Arts Foundation has taken reasonable steps to provide equipment and skilled employees so yourself, your spouse, or your child can participate in activities for which he/she may not be skilled in, we do remind you that these activities are not without risk. Certain risks cannot be eliminated due to our program's setting and without destroying the unique character of those activities. The same elements that contribute to the character of these activities can be cause of loss or damage to your property, accidental injury or illness or, in exteme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to be informed and know in advance about inherent risks.

For promotional or marketing purposes, Sentito Arts Foundation reserves the right to use any audio, video, and/or photography of guests or attendees participating at program facilities.

I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless Sentito Arts Foundation, its officers, board, agents or employees, for any and all claims for injuries, causes of action, or liability related to my child's participation in any activity occurring at the event location. This release does not apply to intentional and/or willful acts of misconduct by Sentito Arts Foundation or any of its officers, board, agents or employees.

Should Sentito Arts Foundation, or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold Sentito Arts Foundation harmless for all such fees and cost.

By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my child's participation in these activities, I and/or my child may be found by court of law to have waived any right to maintain a lawsuit against Sentito Arts Foundation on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and agree to be bound to its terms.

Health or Behavioral Conditions:

Drug Allergies or Other Allergic Reactions:

Dietary Needs/Restrictions:

Medication Taken Regularly:

Activity Restrictions:

I give permission for my child to attend these activities. I understand that my personal insurance will provide primary coverage for medical aid. I also understand that if myself or my child must be sent home because of disciplinary or other problems, I will assume the additional transportation cost. IN CASE OF MEDICAL EMERGENCY, I hereby give permission to the physician selected by the program director or his/her agent to hospitalize, secure proper treament for, and order injection, x-ray, anesthesia, or surgery for my child as named previously.

My child is immunized against the following according to H.E.W standards: Polio, Measles, Mumps, Rubella, Diphtheria, Tetanus, and Whooping Cough. (Please notify the program if this child has been exposed to any communicable disease during the two weeks prior to program attendance.)

My child is not immunized.

Insurance Company:

Policy Number:

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.

Signature*

Registration*

Program Fee $65.00

Registration Fee
Item subtotal:$0.00

Subtotal $0.00Tax $0.00Total $0.00

T-Shirt Size*