PERMISSION FORM

           THIS FORM MAY ONLY BE COMPLETED BY THE CHILD'S PARENT OR LEGAL GUARDIAN.

When registering your family with Little Hands Art Centerfor the first time, please read our Policies and complete and submit this form no later than the first day of class.  A single one-time form is required per family and covers any sibling listed below.  Please notify us if any information in this form changes, and for children who attend regularly, we require an updated form every 12 months.

ABOUT YOU:

Name*

First and Last Name:*


Please indicate whether you are the parent or legal guardian*

Parent/Legal Guardian:

THIS FORM MAY ONLY BE COMPLETED BY THE CHILD'S PARENT OR LEGAL GUARDIAN.


Email:*

Relationship to child(ren):*

Address:*

Address Line 1:*

City:

State:

Zip code:

                                                       

Daytime Phone:*

Evening Phone:*

Cell Phone:*

2nd Emergency Contact Person (other than you):*


First Name*

Last Name*

2nd Emergency Contact Phone Number:*


Name, relationship & phone number of all caregivers that have your consent to pick up your child(ren), if applicable. 


Specifically include other parent, as that is not assumed.

Ex: Jane Doe, grandmother, 704-555-1212






ABOUT YOUR CHILDREN

Please list all children in the family, regardless of whether registering for a class or camp now or in the future.

How many children do you have?*

Child's Name:*

First Name:*

Last Name:*

Child's Date of Birth:*

Month:

Year:

Allergies and/or other medical conditions?*

Yes/No


Any special needs, behavioral or development issues (such as ADHD, autism, downs syndrome, CP, etc.), or other important information that would be helpful for us to know?*

Yes/No (Ex: my child is sensitive to noise and/or crowds and needs to take a break to a quiet place for a few minutes)






Temperament: Please circle all that apply*(and please use back of paper if you need to explain anything in detail)


Outgoing / Social/Shy / Take it Slow/Adaptable/Cautious/High Activity Level/Low Activity Level/Short Attention Span/Long Attention Span

PERMISSION / AUTHORIZATION

I hereby authorize/consent myself, my child(ren) and/or my child(ren)'s caregiver to participate in Little Hands Art Center  art activities, except as noted below:

I grant permission for the staff at Little Hands Art Center to take any and all necessary steps to obtain emergency medical care for my child(ren), if warranted in their sole discretion, and agree that any expenses associated with any medical care will be my responsibility. In all cases of emergency, the child's welfare will be the primary focus; however, every reasonable attempt will be made to immediately reach the Parent/Guardian or designated caregiver. These steps may include, but are not limited to, the following:

• Administering first aid / CPR
• Calling an ambulance or paramedics
• Taking the child to the nearest hospital emergency room in the company of a staff member, in a staff member’s vehicle
• Administration of reasonable medical care as determined by medical personnel in their professional judgment, including, but not limited to, surgery and administration of anesthesia


Please list any Little Hands Art Center art activities in which you specifically do not want your child(ren) to participate, if any:




ASSUMPTION OF RISK, RELEASE, WAIVER AND INDEMNIFICATION

I hereby acknowledge, agree, and accept the risk of injury inherent in any physical activity or program, including particularly, the activities offered by Little Hands Art Center.  Such risks may include but are not limited to falling, bumping, risks from abrasions, scrapes, cuts, broken, sprained or bruised limbs, choking, injury to eyes, consumption or inhalation of paint or other media, allergic reactions, as well as risks from the actions or omissions of others.

Little Hands Art Center exercises reasonable care and precautions to minimize the risk of food-related allergic reactions during snack time, including implementing, communicating, & enforcing strict no-nut snack policies; however, Little Hands Art Center does not in any way ensure that the risks are completely mitigated, nor does it assume liability for any food-related allergic reactions. We require all children who are prescribed an epi-pen, inhaler, diabetic monitor or other medical device carry it with them at all times while on the premises. Parents/Guardians assume full responsibility for their child's allergies and other medical conditions.

As such, I hereby release, discharge, indemnify and hold harmless Little Hands Art Center: its owners, members, managers, instructors, affiliates, agents, employees, successors and assigns, from any and all injuries, illnesses, medical conditions, medical care, death, damages, claims, liabilities, expenses or judgments, including attorneys’ fees and court costs resulting from my, my child(ren)'s, or my child(ren)'s caregiver’s participation in a program or presence on Little Hands Art Center premises or other location where Little Hands Art Center may conduct art instruction, except as such may arise out of Little Hands Art Center’s gross negligence.

I expressly agree that Little Hands Art Center may use photos, video, sound recordings taken of me and my child(ren), for any purpose, including use for publicity. In addition, I agree that Little Hands Art Center shall have a fully-paid, perpetual license to use photographs, copies or reproductions of any work of art produced in its studio by me or my child(ren).

I hereby release Little Hands Art Center from any damage or loss to any of my personal property.

I understand and agree to all of the terms of this Permission Form and all questions that I may have had related to this Form have been answered to my satisfaction, and I understand that this constitutes a waiver and release of liability of Little Hands Art Center. I acknowledge receipt of and agree to the Little Hands Art Center Policies (hyperlinked herein, and located on our website at http://www.littlehandsartcenter.com/policies/).

SIGNATURE AND SUBMISSION INSTRUCTIONS

By entering your name below and the date, this constitutes your signature of this form.  

Signature*

First/Last Name* Date:*