Adult Registration

Name

This field is for validation purposes and should be left unchanged.

I am registering for a class/workshop/performance which will be held at CREATIVE COMMUNITY SPACE. I understand that artistic endeavors can have risks. I agree to hereby release Creative Community Space and owner Vandy Leigh from and for any and all liability which may arise from damages, loss or injuries, either to person or property, which I may sustain while engaging in the activity conducted including, but not limited to, any damages, loss or injuries that may be sustained. I further agree to assume responsibility for any liability which may arise from damage to property or a person’s physical body caused or contributed to by me. Should any injury occur to me, I grant permission for me to receive emergency first aid if I am unable to make this decision for myself. I also agree I can receive treatment from an appropriate health care provider to be selected by Vandy Leigh when in her opinion the need for such treatment is immediate, and contact with my designated emergency contact person is unsuccessful. I also agree to pay and be responsible for all medical, hospital, emergency transportation or other expenses which Creative Community Space, Vandy Leigh may incur as a result of securing such treatment.

Name(Required)

First Last

Home Address(Required)

Street Address City State

Phone(Required)

Email(Required)

Emergency Contact(Required)

First Last

Relationship to Student(Required)

Emergency Contact Phone(Required)

Please list any Allergies that you have

Medication that might be important to know you are currently taking

Any other issues we should be aware of to provide you with the most positive experience possible.

I grant permission to be photographed or filmed. Images to be “published”/used on (check all that apply)

teacher’s website

Instagram

CCS’s website

Facebook

for publish in the newspaper

for educational use

my FIRST name only may be used

my name may not be used in any form

Class Information

Class Name(Required)

Date(Required)

Cost of Class(Required)

Total

Type out Name (this acts as your signature)(Required)

Date

Coupon

Payment Method