1/2 Day Week Camp

1/2 Day Week Camp

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

Date of Class *

Youth First and Last Name *

Youth Date of Birth *

Youth Age *

Youth (2) First and Last Name (Only need to complete if more than 1 child)

Youth (2) Date of Birth (Only need to complete if more than 1 child)

Youth (2) Age (Only need to complete if more than 1 child)

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

Parent/Guardian Name *

Parent/Guardian Phone *

Parent/Guardian Email *

Emergency Contact First & Last Name *

Emergency Contact Relation *

Emergency Contact Number *

Parent/Guardian Address *

Comments

Please provide a digital signature *

Clear

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.

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.