Summer @ The Center

1st Student Name *

First Name

Last Name

2nd Student Name, if applicable

First Name

Last Name

Primary Adult Emergency Contact Information *

Please fill in the following information for the adults that are responsible day-to-day, and are primary contacts for the child. In the event of an emergency, I will contact the following person(s) in the order presented:

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Second Adult Emergency Contact Information *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

MEDICAL CONSENT WAIVER AND RELEASE OF LIABILITY *

* I authorize my child to walk to the rail trail with Center staff for outdoor exploration of themes. * I authorize The Center staff to administer emergency first aid when appropriate. * I understand that every effort will be made to contact me in the event of an emergency where my child requires medical attention. * I authorize a Center staff member to transport my child or to secure transport to Anna Jaques Hospital and to secure necessary medical treatment from the physician on duty. * In the event of serious illness or injury not requiring emergency treatment, I understand that I will be called and asked to take my child home or to a physician. I authorize the person(s) listed to be contacted in the event of an emergency. * I understand ONLY the person(s) listed will be allowed to release my child with prior notification. * I agree to release, hold harmless, and discharge The Center, and all of its employees, volunteers, contractors, and representatives from any and all claims or causes of action. I waive any right to legal action for personal injury or any associated costs that may arise from this child(ren)'s participation in any activities or use of the facilities. * I agree to pay all medical expenses not covered by my insurance.

I agree

I authorize The Center to release the information on this form to the hospital. *

I agree

I have carefully read this WAIVER AND RELEASE, understand, consent, and grant authority as noted above. *

I agree

Photo Release and Waiver *

I hereby grant permission to The Center: Art + Community, its employees, volunteers, and agents, to photograph, videotape, or otherwise record myself and/or my child during participation in any classes, events, or activities. I understand that these images and recordings may be used for promotional materials, social media, website content, fundraising efforts, and other forms of publicity related to The Center. I waive any rights to inspect or approve the finished product or the use to which it may be applied. I understand that no compensation will be given for the use of these images.

My child can be photograpghed.

Please add my child to the Do Not Photo List

Parent Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY