Parent/Guardian 1

Full Name: *

Relationship to Child: *

Address: *

Zipcode: *

Cell Phone:

Email: *

Home Phone:

Place of Employment:

Work Phone:

Parent/Guardian 2

Full Name:

Relationship to child:

Address:

Zip Code:

Cell Phone:

Email:

Home Phone:

Place of Employment:

Work Phone:

Parent/Guardian 3

Full Name:

Relationship to child:

Address:

Zip Code:

Cell Phone:

Email:

Home Phone:

Place of Employment:

Work Phone:

Art, Photo, Web and Video Release Permission

My child/children has my permission to participate in art shows and to have artwork displayed or printed.: *

Yes No

My child/children may be photographed for print, Art House web page, Facebook, Instagram, videotaped and audio tape recorded. I understand that these materials can be used in publications, news releases, online and in other communications related to the mission of the Inner-City Neighborhood Art House.: *

Yes No

Students that will be attending the Inner-City Neighborhood Art House are:

Student 1

Student Name: *

Ethnicity: *

Gender: *

Age: *

by Jun. 20, 2022

Birth Date: *

Child lives with:

Guardian 1
Guardian 2
Guardian 3

School Attending: *

Grade: *

IEP: *

Children’s Allergies or Food Restrictions:

Any Physical Restrictions or Medical Particulars:

(Example: Daily Medications, etc.)

Student 2

Full Name:

Ethnicity:

Gender:

Age:

by Jun. 20, 2022

Birth Date:

Child lives with:

Guardian 1
Guardian 2
Guardian 3

School Attending:

Grade:

IEP:

Children’s Allergies or Food Restrictions:

Any Physical Restrictions or Medical Particulars:

(Example: Daily Medications, etc.)

Student 3

Full Name:

Ethnicity:

Gender:

Age:

by Jun. 20, 2022

Birth Date:

Child lives with:

Guardian 1
Guardian 2
Guardian 3

School Attending:

Grade:

IEP:

Children’s Allergies or Food Restrictions:

Student 4

Full Name:

Ethnicity:

Gender:

Age:

by Jun. 20, 2022

Birth Date:

Child lives with:

Guardian 1
Guardian 2
Guardian 3

School Attending:

Grade:

IEP:

Any Physical Restrictions or Medical Particulars:

(Example: Daily Medications, etc.)

Any Physical Restrictions or Medical Particulars:

(Example: Daily Medications, etc.)

EMERGENCY CONTACTS IF PARENT/GUARDIAN CANNOT BE REACHED:

Full Name:

Relationship to child:

Address:

Phone:

Full Name:

Relationship to child:

Address:

Phone:

**Parent/GuardianDigital Signature: *

Date: *

THE INNER-CITY NEIGHBORHOOD ART HOUSE PARTICIPATION AGREEMENT

I, the parent/legal guardian of my child (also known as registrant/s), a minor, agree to my child’s participation in the Inner-City Neighborhood Art House. It is understood that participation in such activities has an inherent risk of injury to the registrant. I, for myself, family members and the registrant, release and hold harmless the Neighborhood Art House, its employees and volunteers from any and all liability for injury to the registrant arising from participation in the Neighborhood

** Parent/Guardian Signature: *

Date: *

I give my full consent to the Inner-City Neighborhood Art House and any medical professionals to administer whatever emergency medical treatment is deemed necessary for the registrant/s in the event of an unforeseen injury or illness.

I acknowledge that my son/daughter has no known allergies or medical conditions except as noted below (If none, state NONE): *

INSURANCE

I confirm that the registrant is covered by a personal or family medical insurance including hospitalization:

Doctor's Name:

Phone:

Medical Insurer:

Group:

Policy #:

Hospital Preference:

**Parent/Guardian Signature: *

Date: *

Parent/Guardian’s Permission Regarding Emergency Medical Care

Student/s Name/s:

I, the undersigned parent/legal guardian, do hereby grant permission to any licensed physician to perform or provide necessary emergency medical care or aid to my child (also known as registrant),

(child(ren) name):

, in connection with the Inner-City Neighborhood Art House program. I am aware any and all costs associated with said care are my responsibility.

** Parent/Guardian Signature: *

Date: *

Note: Does/Do the registrant/s have any mental or physical condition/s that might require special attention?:

Yes
No

If Yes, please explain:

I, the undersigned parent/legal guardian, have read and understand all of the above. Subject to the above, I agree to the registrant/s participation in Inner-City Neighborhood Art House activities for the period from June 20, 2022 until December 31, 2022

** Parent/Guardian Signature: *

Date: *

Have you or any member of your family ever attended the Art House?:

Yes
No

Session Ticket for February 28- April 3, 2024

I would like at $30. each = $0

Session Ticket for April 17- May 22, 2024

I would like at $30. each = $0

Register for upcoming six-week sessions for Spring of 2023

Parent/Guardian 1

Parent/Guardian 2

Parent/Guardian 3

***Art, Photo, Web and Video Release Permission***

Students that will be attending the Inner-City Neighborhood Art House are:

Student 1

Student 2

Student 3

Student 4

EMERGENCY CONTACTS IF PARENT/GUARDIAN CANNOT BE REACHED:

THE INNER-CITY NEIGHBORHOOD ART HOUSE PARTICIPATION AGREEMENT

INSURANCE

Parent/Guardian’s Permission Regarding Emergency Medical Care

Session Ticket for February 28- April 3, 2024

Session Ticket for April 17- May 22, 2024

Art, Photo, Web and Video Release Permission