Class Registration Form Class Start Date * Class End Date * Class Time * Family Name * Email * Child's Name * Male/Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent 1 * Please Enter: Name, Cell #, Email, Occupation, Address Parent 2 Please Enter: Name, Cell #, Email, Occupation, Address Emergency Contacts (other than parents) * Please List 2: Name, Relationship, Phone# Toilet Trained * Yes No If not, what stage Allergies * Medications * What words to you use to describe bodily functions? What are some of your child’s favorite things? (Toys, Activities, Pets, Etc.) How did you hear of the class * Past experience in Pre-School or Day Camps? What do you hope your child will gain from his/her school experience Do you or other family members have interest, skills or hobbies which you would like to share with the children and the staff? Any family situations or problems which might hinder child’s adjustment? Is there any additional information you would like to share with us about your child? PHOTOGRAPHIC LIKENESS RELEASE ----> From time to time, InspiredArt, LLC (InspiredArt) and/or its agents photographs participants in venues, of child related activities in connection with its marketing and promotion efforts. By signing this document below, you agree to the following terms and exclusive grants to InspiredArt: You hereby expressly give consent to InspiredArt to photograph your child, and you grant InspiredArt the exclusive right to use your minor child's photograph and physical likeness, whether one or more photographs (the "Photograph") in connection with any InspiredArt advertising, promoting, displaying, and/or marketing, as well as any future use of the Photograph to advertise, promote, display and/or market InspiredArt services, and for public relations purposes connected with the InspiredArt, including without limitation use in InspiredArt brochures and website(s). The rights and release created herein shall apply to all media now known or later developed and to all trade channels. You acknowledge that InspiredArt, is the. sole, exclusive, and perpetual owner of the Photograph which ownership entitles InspiredArt, among other things, to exclusive and perpetual: Ownership of all duplicates or derivatives of any Photograph and any displays or promotional materials; Right to control, display and use the Photograph and any performance rights embodied therein; Right to reproduce, modify, distribute, manufacture, advertise, sell, lease, license or otherwise use or dispose of such Photograph; and Right to use and display such Photograph in any medium by any means and for any purpose whatsoever. You hereby waive the opportunity and right to inspect or approve any reproductions of the Photograph or any use to which they may be put. InspiredArt has no obligation to use the Photograph. You hereby agree to release and hold harmless InspiredArt, its officers, trustees, agents and employees, and those acting under InspiredArt authority, against loss from any claim, action or demand that may be brought at any time by myself or by anyone acting on my behalf or by the above-named minor or by anyone acting on the minor's behalf for the purpose of enforcing a claim for damages on account of the use or non-use of the Photograph or likeness, and from all claims and liabilities of any kind arising out of or in connection with the use and reproduction or non-use of the Photograph or the likeness referred to above. By checking the box below, you certify and represent that you have read the foregoing and fully understand the meaning and effect thereof. Also, by signing this agreement, you intend to be legally bound by it. I hereby give my consent for the photographic release: * Yes No ---------DISMISSAL INFORMATION I Hereby Give Permission For the Following Persons to Pickup My Child From: * Pickup Person 1 - Last Name, First Name, Phone # Pickup Person 2 - Last Name, First Name, Phone # Pickup Person 3 - Last Name, First Name, Phone # Pickup Person 4 - Last Name, First Name, Phone # Selecting "Yes" Authorizes InspiredArt to Release the Above Named Child to Any of Listed Persons the * Yes No Thank you! Please fill out this form to the best of your abilities. It is required for class!
