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 No My child will need to be picked up at school (Please contact your teacher to arrange for this)(Required) Yes No My child may walk home(Required) Yes No My youth will be driving themselves(Required) Yes No Section BreakI understand that artistic endeavors can have risks. I agree to hereby release Creative Community Space, Vandy Leigh, and anyone acting in her place, 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, or person acting in her place, when in their 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.Section BreakHome Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 hasPlease list any Medications that the child is currently takingBehavioral or other issues we should be aware of to provide you child with the most positive experience possibleI 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 InformationClass Name(Required)Date of Class(Required) Cost of Class(Required) Total Type out Name (this acts as your signature)(Required)Date Coupon Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name *If making a payment, please wait on page during/after submitting paypal payment, page will refresh with confirmation once complete
