Minor Intake Form

Participant Name(Required)

First Last

Age(Required)

Date of Birth(Required)

Name of parent(s)/guardian(s)(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does participant have a life-threatening allergy/condition?(Required)

Yes

Please outline further details

Does participant have an epi-pen?(Required)

Yes

Does participant require assistance in order to participate in this program?(Required)

Yes

(Note: We welcome you to bring support, caregiver or family member if you require personal care support for participation and/or changing, transferring, washroom assistance, or administration of medication.)

Please outline further details

Does participant have behaviours that staff should be aware of?(Required)

Yes

Please outline further details

Is there anything else we need to know about the participant?(Required)

Yes

(Please Note: This information helps staff determine if we can safely accommodate the participant in our programs. If you have indicated “Yes” to any of the above questions, please connect with us. (for example: medical conditions, dietary restrictions, general allergies, fears, etc.) We believe in providing inclusive recreational opportunities for everyone in the community. Children and youth with disabilities that require additional support are encouraged to bring a caregiver or family member with them.

Please outline further details

Pickup Authorization & Emergency Contact(Required)

Photo Release(Required)

Yes

I agree to give McTavish Academy of Art permission to use photo or video of myself or my child for educational and promotional purposes. I understand that my child will not be identified by name unless given permission, nor will compensation be extended for such use.

Release & Waiver of Liability(Required)

Yes

Agreement of Release & Waiver of Liability

I agree to the release & waiver of liability

I hereby agree to the following. My child has permission to attend classes offered by McTavish Academy of Art facilitated by RNS Dance and instructors.

My child is participating in classes or services during which they will receive information and instruction about art, yoga, dance, music, health or wellness. I recognize that such classes/services require physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I understand it is my responsibility to consult with a physician prior to and regarding my child’s participation in any physical fitness program. I understand my child has no medical condition that would prevent their participation in the class or any physical fitness activities.

I agree to assume full responsibility for any risks, injuries or damages, known and unknown, which my child might incur as a result of participating in this class. I knowingly, voluntarily, irrevocably and unconditionally release, discharge and waive any claim I may have against McTavish Academy of Art, the Instructor, owner of or leaseholder of the building and their respective agents, consultants, advisors, and successors. (Including RNS Dance who facilitate Dance Programs)

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
I agree to each statement above and release McTavish Academy Of Art and Instructors from any and all liability for the unintentional exposure or harm due to COVID-19 or other communicable disease.

Parent/Guardian name(Required)

First Last

Authorization Date(Required)

Title