Affiliate 1 or 2 Application and Release Form

AFFILIATE ADULT APPLICATION & RELEASE FORM

THIS FORM IS FOR ALL CERAMICS AND PAINTING/MIXED MEDIA OR STUDIO CLASSES. Affiliates may attend up to two ceramics and/or painting classes per week. Drop In for a single class is also available. Complete one form PER ADULT. Check molokaiartscenter.org/calendar/ for current class schedule.
NOTE: Prices will increase March 1, 2024, the first increase in 14 years. Affiliate 1 Fee $70; Affiliate 2 Fee (Volunteer) $40; Drop In $25.

Current Protocols:

MAC protocols remain consistent with County, State, non-profit arts associations, and CDC guidance to mitigate the spread of COVID-19 and other transmittable viruses. Participation in any MAC activity requires acceptance of current protocols.

No host, no entry. NO ONE is allowed on the premises without one of the instructors/hosts listed on the web calendar during scheduled times, unless the Studio Manager has given you written permission. Our instructors/hosts have received training on safety and health protocols and need to be present to assure a safe environment for all users. If you have received express permission from the Studio Manager to be on the premises without a scheduled instructor/host, make sure it is via written form (text or email).

Studio use guidelines are based on current CDC best practice for businesses (profit and non-profit) and adjusted to the MAC’s space and population. Protocols may change as county/state/federal guidelines remain fluid. It will be each individual's responsibility, as members and staff, to help keep the studio open and safe. At all times, please respect one another’s choices. We appreciate your kokua.

Please act with care. Stay at home if you are ill. Help to keep our work spaces clean and sanitized.
Title*
Your Name*

First NameLast NameSuffix
Name on Billing Information (i.e. business name)
Your E-mail*

Confirmation Email
Main Phone Contact*
Type of phone*
Alternate Phone Contact
Alternate Type of phone
Mailing Address*

Street Address

Street Address2/PO Box

CityState

Zip CodeCountry
Molokai Address*

Street Address/Residence-Hotel/Condo Number

Mailing Address/P. O. Box (REQUIRED for residents)

CityState

Zip Code
Do you require reasonable accommodation for a special circumstance/handicap? What type of accommodation?
Demographic information below may be used for reporting requirements but will not be attached to names.
Are you a (select one)*

Resident - Full TimeResident - Part-timeVisitor - HawaiiVisitor - MainlandVisitor - International
If you are not a Molokai resident, where are you from? Be sure to TYPE N/A if not applicable.*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Age group*

Adult 18+Senior/KupunaYouth/'Opio 13-17Child/Keiki 3-12
Race (you may select more than one)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American: A personnel having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Are you a current

Individual Annual Member $45/yrFamily Annual Member $75/yrFriend Annual Member $100+/yrPatron Annual Member $500+/yr
YOU WILL NEED TO RETURN TO THIS PAGE IF YOU CLICK ON ANY OF THE FOLLOWING LINKS.

Annual Members help to keep the MAC open AND keep our Affiliate fees down. If you are an Affiliate, but not an Annual Member, please consider becoming one to take advantage of 20% off affiliate fees (Friend or Patron members only).

Visit Annual Membership Form to become an Annual Member or renew your Annual Membership. Then return to this page to continue sign up.

We welcome donations throughout the year to help sustain MAC programs. Make a tax deductible donation here: MAC 501c3 charitable donation Then return to this page to continue sign up.
Liability Release Form & Emergency Contact Information

All activities involved in making art and/or ceramics include some minor health hazards which we will attempt to minimize, including but not limited to inhalation of minute amounts of clay dust and exposure to raw glaze materials for advanced and intermediate students.

I understand that participation in the above activity or event may be hazardous for the above-named participant(s).

In signing below,
- I have read and will abide by current studio use protocols.
- I assume that injury risk or harm that may occur to the participant(s) listed above as a result of participating in the Molokai Arts Center events or activities. *note special circumstance/handicap next to person's name for reasonable accomodation*
- I hereby release the Molokai Arts Center and its officers and board members or agents from any liability, costs and damages resulting from participating by the above-named individual(s).
- I also give my consent for the Molokai Arts Center to seek emergency treatment for myself if necessary, and I agree to accept the financial responsibility for the costs related to the emergency treatment.
- I hereby authorize the Molokai Arts Center to publish photographs of above-named participant(s) for use in print, online, and video-based marketing materials as well as MAC publications. I further acknowledge and agree that neither I, the minor child, nor minor children will receive financial compensation for any type for these photos and that publication of said photos confers no rights of ownership or royalties whatsoever.
Who should we contact in case of emergency?
Emergency Contact Name*
Emergency Contact Relationship*
Signed (Print Name)*
Today's Date*

MonthDayYear
Date
If payment is being made by someone or entity other than named above, please enter name here.
If you are paying for more than one month, please list months here and select appropriate quantity.

My Products

Adult - Affiliate 1$70.00

Benefits include: *Open Studio Time *Access to weekly classes *Free supplies & materials used in studio *All publications *Invitations to all events *10% off merchandise & supplies *20% off workshop discounts

Quantity

Adult - Affiliate 1 and Friend/Patron Annual Member$56.00

same Benefits as Affiliate 1 Discounted 20% for Friend Members and Patron Members

Quantity

Adult - Affiliate 2 (Volunteer)$40.00

This Level requires an 8 hour per month volunteer commitment as determined by the MAC management. Benefits same as Affiliate 1.

Quantity

Adult - Affiliate 2 (Volunteer) and Friend/Patron Member$32.00

Same as Affiliate 2 with discounted 20% for Friend Members and Patron members.

Quantity

Affiliate CASH or CHECK (Bring Invoice to MAC)$ Free

Check here if you will pay via CASH or CHECK at the MAC studio. Remember to bring a copy of your INVOICE with payment.

Quantity

Enter coupon

Subtotal $0.00Tax $0.00Total $0.00

DON'T FORGET TO click "Go to Payment Page" to complete form! Payment is not confirmed until you click that button. Selections marked FREE will still need to Go To Payment Page to generate invoice for payment at the MAC.

You will receive email confirmation from Jotform and Paypal. Please use these as proof of payment for host/instructor.

After you complete this form, save this link to pay your Affiliate dues every month. https://bit.ly/4cgK1FZ
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AFFILIATE ADULT APPLICATION & RELEASE FORM