Child/Youth Registration

I represent that I am the parent/guardian of the child listed below. I grant permission for my child/youth to participate in the class/workshop to be held at CREATIVE COMMUNITY SPACE.

Parent/Guardian Name(Required)

First Last

Child Name(Required)

First Last

Child's school grade level or equivalent(Required)

I will transport my child/youth to this class/workshop/performance.(Required)

Yes

My child will need to be picked up at school (Please contact your teacher to arrange for this)(Required)

Yes

My child may walk home(Required)

Yes

My youth will be driving themselves(Required)

Yes

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I understand that artistic endeavors can have risks. I agree to hereby release Creative Community Space and Vandy Leigh from and for any and all liability which may arise from damages, loss or injuries, either to person or property, which my child/youth may sustain while engaging in the activity conducted including, but not limited to, any damages, loss or injuries that may be sustained through transportation, including by foot, to and from the activity. 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 my child/youth. Should any injury occur to my child/youth, I grant permission for my child/youth to receive emergency first aid. I also agree my child/youth 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 when efforts to contact me or my designated emergency contact person are unsuccessful. I also agree to pay and be responsible for all medical, hospital, emergency transportation or other expenses which Creative Community Space and Vandy Leigh may incur as a result of securing such treatment.

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Home Address(Required)

Street Address City State

Phone(Required)

Email(Required)

Emergency Contact(Required)

First Last

Relationship to Student(Required)

Emergency Contact Phone(Required)

Your Employer(Required)

Family Physician(Required)

Health Insurance Provider and ID #(Required)

Please list any Allergies that the child has

Please list any Medications that the child is currently taking

Behavioral or other issues we should be aware of to provide you child with the most positive experience possible

I as parent/guardian of minor child/youth listed on this form grant permission to photograph or film my child/youth. 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 child’s FIRST name only may be used

my child’s name may not be used in any form

Class Information

Class Name(Required)

Date of Class(Required)

Cost of Class(Required)

Total

Covid Screening: During classes at Creative Community Space masks are highly recommended. Vaccination for Covid is highly recommended. Before attending a class you should be able to answer “No” to these questions. Have you tested positive for COVID-19 in the past 10 days? Are you currently awaiting results from a COVID-19 test? Have you been diagnosed with COVID-19 by a licensed healthcare provider (for example, a doctor, nurse, pharmacist, or other) in the past 10 days? Have you been told that you are suspected to have COVID-19 by a licensed healthcare provider in the past 10 days? I do this with full knowledge and consent and waive all claims for compensation for use, or for damages.

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

Date

Coupon

Payment Method