Child Registration Form

Student Information

Student's Name *

First Name Last Name

Age *

Gender *

Male Female Alternate

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian Information

Parent(s) Name *

First Name Last Name

Best Number to Reach You *

Area Code Phone Number

Email *

example@example.com

Emergency Information

Emergency Contact's Name (Must be someone other than number listed above) *

First Name Last Name

Emergency Contact's Phone *

Area Code Phone Number

Does the student have any severe allergies, chronic illness, or other special needs? If yes, please describe:

Informed Consent and Acknowledgement

By completing this form I give Art Barn School of Art, Inc. permission to use my image/my child’s image, as will as images of my/his/her artwork for purposes of promotion in connection with Art Barn.

No registration will be taken without full payment. Refunds issued minus a $25 fee through the first class.

No refunds permitted after that time. No refunds on workshops unless cancelled by Art Barn School of Art.

I hereby give my approval for my child’s participation in any and all activities prepared by Art Barn School of Art, Inc (Art Barn) during the selected camp. In exchange for the acceptance of said child’s candidacy by Art Barn, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Art Barn 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 Art Barn including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

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 student. 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 the Art Barn School of Art, Inc. and its affiliates including Directors, Coaches, and Team Parents 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.

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.

Please Choose a Class or Classes

Comprehensive Art, Thursdays, May 7-28, 3pm-4pm, Ages 10 + $ 40.00

ARTastic Saturday, Session 4, May 2-30 ( 5 week session) $ 65.00

Drawing Cafe, Tuesdays, 2pm-3pm, April 7-28, Ages 13 + $ 40.00

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Total $ 0.00

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