Youth Program Registration, Permission, and Waiver Form-claystudioofmissoula

Youth Program Registration, Permission, and Waiver Form

Child's First Name

Child's Last Name

Age

Pronouns

Parent/Guardian Full Name

100

Parent Phone Number

Parent Email

Emergency Contacts

Below, please provide information for two contacts we can reach if the parent/guardian is unavailable in case of an emergency.

Emergency Contact 1 Full Name/Phone Number/Relationship to Child

Emergency Contact 2 Full Name/Phone Number/Relationship to Child

Ability to Engage in Art Activities and Assumption of Risk:

Activities at The Clay Studio of Missoula include but are not limited to clay, underglazes, slips, ceramic tiles, plaster, paints, markers, pencils, pencil sharpeners, scissors, glues, wire, fiber (yarn/ fabric/papers), walking to nearby Westside Park and playing outdoor games. The Clay Studio of Missoula takes all possible precautions to reduce risk and provide safe, healthy, and enjoyable experiences. I warrant that my child is able to follow directions for all activities in class. I acknowledge that risks from participation in class activities exist and that I have allowed my child to attend art class/events knowing these risks and their possible consequences including personal injury as well as property damage and/or loss.

Waiver and Release of Liability:

As a parent or guardian of my child, I agree that I will not hold The Clay Studio of Missoula liable for any personal injury, property damage, or loss of insurance. I agree to release and hold The Clay Studio of Missoula from all liability incurred as a result of my child’s participation at The Clay Studio of Missoula and that these terms serve as a release for myself, volunteers, property owners, and members of my family.

I have read and agree to the above assumption of risk and release of liability.

The Clay Studio of Missoula is granted permission to use group or individual photo images taken during class/events for publicity or promotional purposes.

Yes

Emergency Medical Care:

I know of no health or fitness restriction(s) that precludes their participation. In the event of illness or injury occurring to my child while involved in this activity, I authorize X-ray examination,anesthesia, medical, dental, or surgical diagnostic procedures or treatment and hospital care that is considered necessary in the best judgment of the attending physician and performed by or under the general or special supervision of any physician or surgeon, licensed under the Provision of Medicine Practice Act, or of any dentist under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office/studio, hospital, or elsewhere. It is understood that in the event of a serious illness or injury, reasonable efforts to reach me will be attempted.

I hereby release from liability all persons affiliated with The Clay Studio of Missoula who in any fashion have helped in organizing, planning, and/or implementing classes or events for The Clay Studio of Missoula. I understand this activity is voluntary and I desire for the above named minor to participate in it.

Insurance Company

ID #

Is there anything important we need to know to best accommodate your child? (Allergies to art supplies, dietary restrictions, emotional/mental/behavioral differences such as ASD, health concerns such as asthma, etc.)

Your Signature

Today's Date