Youth Academy Waiver Form Online : Scottsdale Artists' School

Date*

Child's Name*

First Last

Birthday*

Boy/Girl*

Name of Class/Camp*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Name*

First Last

Phone*

Alternate Phone Number

Email*

Emergency Contact*

Emergency Phone*

Friend or Relative we can contact if you are not available*

Phone Number of the above Friend or Relative*

Health Insurance Company / Policy Number

Are there any behavior or medical issues we need to be aware of (please note that Exceptional Student Services are not available)

Drug/Food Allergy

Other Allergies

Special needs

By signing this agreement, I/We the undersigned parent(s)/guardian(s) of this youth do understand that Scottsdale Artists’ School (instructors and staff) are acting only as agents and shall not be responsible or liable for any injury/ accident/illness, which may occur on site or within the duration of class time. Please be aware that we must be able to reach you in the case of an emergency. All classes will be conducted with utmost care in a safe learning environment. Please make arrangements to drop off and pick up your child on time. No child will be released without proper authorization from the parent/guardian in advance. For their safety, each day every child must be signed in and out.

Signature*

I/We the undersigned parent(s)/guardian(s) of this child do hereby authorize Scottsdale Artists’ School (instructors and staff) to make any and all decisions and to authorize and consent to, any and all emergency medical care deemed necessary, to be rendered to the above named youth for their care and safety. The undersigned understands that reasonable and diligent efforts will be made to locate or contact the undersigned in an effort to obtain consent to all medical treatment unless delay in such treatment would be unwise. The undersigned takes full responsibility for any financial cost which may be incurred for the care of the above named youth.

Signature*

Scottsdale Artists' School sometimes has press agents from local TV, Radio, newspapers, etc. on property to highlight its programs. I understand and agree as the undersigned parent(s)/guardian(s) of this youth that the Scottsdale Artists' School may photograph and videotape my child and his/her artwork created in class for part of its publicity, promotional and archival purposes. I do hereby release Scottsdale Artists’ School from any claim whatsoever that may arise in said regard.

Signature

Printed Name for the parent(s)/guardian(s) signature above*

First Last

I hereby declare that the signatures above are my legal signature and I am the parent/guardian of the youth on this form.