“‘Education & Wellness, using Arts & Science to bring forth mindfulness, clarity and creativity’”

TASGM: Winter Camp (Single Day)

December 23, 2024

Please have the form completed fully, signed and dated on the bottom

Date of Registration *

Parent/Guardian Name *

Parent/Guardian Phone *

Parent/Guardian Email *

Emergency Contact First & Last Name *

Emergency Contact Relation *

Emergency Contact Number *

Parent/Guardian Address *

List Participants here: *

Participant #1
Participant #2
Participant #3
Participant #4

Participant Birthdate *

Participant #1 - Birthdate
Participant #2 - Birthdate
Participant #3 - Birthdate
Participant #4 - Birthdate

Is there anything we should know? (ie: allergies, etc) *

If other, please explain here

Other *

Please provide a digital signature *

Clear

With this signature, I authorize and consent to my child(ren) to participate in the program. Even though activities are low impact, I understand that with child(ren) accidents can & may happen. I will not hold TASGM and the staff responsible for any injuries. I also understand that workshops are non-refundable. I understand that TASGM and staff are not licensed counselors/therapists. If there is any question or concern, I will notify management.

Photo/Video Release *

Upon signing this form, you give permission to Therapeutic Arts Science & Growth Mindset (TASGM) to utilize and/or publish media/video/photos from workshops or workshop related activities. The nature of the program is to allow participants the freedom of creativity. Photos and/or videos are taken throughout the duration with the following ideas in mind: *To capture the joy of creating *To share the photo/video with participants and/or parents/guardians of participants *To complete projects that may require printing out of photos, or editing of videos inclusive of their own images and/or peers *TESTIMONIALS *Social Media/Marketing Note: Some Photos/Videos/Media May or may not even be used.

“If you could learn in a way that also helps you heal, would you?”

— anonymous

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