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Minor Intake Form
Sean McNeill
2023-01-16T20:50:54-08:00
Minor Intake Form
Participant Name
(Required)
First
Last
Age
(Required)
Date of Birth
(Required)
Month
Day
Year
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
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Nigeria
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Panama
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Virgin Islands, U.S.
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Does participant have a life-threatening allergy/condition?
(Required)
Yes
No
Please outline further details
Does participant have an epi-pen?
(Required)
Yes
No
Does participant require assistance in order to participate in this program?
(Required)
Yes
No
(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
No
Please outline further details
Is there anything else we need to know about the participant?
(Required)
Yes
No
(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
No
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
No
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.
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)
Month
Day
Year
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