Date* MM slash DD slash YYYY Child's Name* First Last Birthday* MM slash DD slash YYYY Boy/Girl* Name of Class/Camp* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent/Guardian Name* First Last Phone*Alternate Phone NumberEmail* 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* Reset signature Signature locked. Reset to sign again 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* Reset signature Signature locked. Reset to sign again 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 Reset signature Signature locked. Reset to sign again 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.