Bloom Children's Studio Class Waiver
Thank you for joining a class at Bloom! This Waiver MUST be signed and submitted before child will be admitted to a class.
Child's First Name
Child's Last Name
Age of Child:
Child's Date of Birth:
Class Name:
How did you hear about Bloom Children's Studio?
Parent/Guardian 1
Phone Number
Email
Parent/Guardian 2 (If applicable)
Phone Number
Email
Address
Address 2 (If applicable)
Emergency Contact Name:
Emergency Contact Number:
Any known allergies or medical conditions? If so, please specify:
Child's Physician:
Physician's Contact number:
I/we grant permission for my/our child to participate in all of the Bloom Studio class activities that take place at Bloom Children's Studio. I/we release and hold harmless Bloom Children's Art Studio from any and all liability that may arise.
Yes
No
I/we understand that Bloom Studio embraces messy play. I/we understand that clothing worn to class may get stained and will dress my/our children in clothing that is meant to get messy. Bloom studio is not responsible for any clothing that is ruined.
Yes
No
The safety of the children at Bloom Children's Studio is a top priority. I/we acknowledge that my/our child has no emotional, physical or social conditions that make it dangerous or unwise to safely participate in Bloom Studio classes.
Yes
No
I/we grant permission for my/our child to be included in photos or promotion connected with Bloom Children's Art Studio, such as website, Facebook, or Instagram.
Yes
No
I/we grant permission for the staff of Bloom Children's Art Studio to take whatever steps necessary to obtain emergency medical care, if warranted. These steps may include, but are not limited to the following: 1. Administer minor first aid 2. Attempt to contact a person, guardian or emergency contact 3. Attempt to contact childʼs physician 4. Attempt to contact the parent through any of the persons listed above 5. If we cannot contact the parent or the childʼs physician, we will do any of the following: a. Call another physician b. Call an ambulance. c. Have the child taken to the emergency room in the company of a staff member in a staff vehicle. 6. Any expenses incurred under item “5” above will be borne by the childʼs family.
Yes
No
Date
Your Signature
*
Clear
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