Tell Us About the Student!
This course is designed for those on the Autism spectrum between the ages of 13 - 19. We're looking forward to having your student as a part of our class! Please fill out the information below to register! Curious if this class is right for your student? Contact Rachel, our accessibility coordinator and course teacher at Rachel.garmon@cszrva.com
Student's Name
*
First Name
Last Name
Current Age
*
Birthday
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Month
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Day
Year
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Current School
*
Current Grade
*
Home Address
*
Street Address
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Home Phone Number
*
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Area Code
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Student's Mobile Phone (if applicable)
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Adult Information
Parent's Name
*
First Name
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Parent's Mobile Phone #
*
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Area Code
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Parent's E-mail
*
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
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Area Code
Phone Number
Medical Information
Please list any allergies your child has (food, medicine, etc)
Please list any medications your child is required to take
Please read the statement below and check the button to give consent
*
By submitting this form, I give my permission to CSz Richmond and its employees to administer any necessary first aid to my child in case of emergency and, if warranted, to take my child to an emergency clinic or hospital, or arrange for professional medical transportation to do so if needed. I understand that CSz Richmond will contact me to inform me of any incidents.
Release of Liability - Please read & check below
*
In consideration of my child's participation in the activities of ComedySportz, I hereby fully release and discharge, and save whole and harmless, ComedySportz Richmond, CSz Richmond Theater, CSz Richmond, Yes Ballon, their owners, officers and employees, their successors or affiliates from any and all liability for damages or claims for damages, causes of action, claims, demands, costs, expenses, and compensation of any nature whatsoever, for any and all known and unknown personal injuries, sickness, illness, or disorder, which my child may now hereafter have, arising out of or in connection with participation in any activities whatsoever of ComedySportz Richmond, the CSz Richmond Theater, CSz Richmond or Yes Balloon. By selecting the button next to this statement and submitting this form, I state that I have read, understood, and willingly agree to this release.
Photography Permission - Please read & check below
*
By submitting this form, I agree to give my permission to CSz Richmond to take photographs of my child and of class activities that include my child, to be used for promotional purposes of CSz Richmond at any future time. I understand that these photographs are the property of CSz Richmond. CSz Richmond will provide a copy of any photographs upon request.
Please submit a separate form for each child registered. Thanks!
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