PARTICIPANT ENROLMENT FORM | The Dreaming Heart

Your first name

Your last name

Your email

FULL NAME OF CHILD #1

DATE OF BIRTH (DD/MM/YYYY)

FULL NAME OF CHILD #2

DATE OF BIRTH (DD/MM/YYYY)

FULL NAME OF CHILD #3

DATE OF BIRTH (DD/MM/YYYY)

FULL NAME OF CHILD #4

DATE OF BIRTH (DD/MM/YYYY)

HOME ADDRESS (street address, city, province, postal code)

FULL NAME OF PARENT/LEGAL GUARDIAN #1

Relationship to the child(ren)

Main Phone #

Alternate phone #

Email address

FULL NAME OF PARENT/LEGAL GUARDIAN #2

Relationship to the child(ren)

Main Phone #

Alternate Phone #

Email address

EMERGENCY CONTACT (other than parents/legal guardians)

Relationship to the child(ren)

Main Phone #

Alternate Phone #

ART CLASS ARRIVAL & DEPARTURE- My child(ren) will...

Be signed in and out by an authorized person

Sign themselves in and out (must be 10+ yrs.)

AUTHORIZED PERSONS- Are the parent(s)/legal guardian(s) and emergency contact(s) listed above authorized to sign-in & sign-out your child(ren)?

Yes

No

N/A, my child will be signing themselves in and out

If you selected NO, please list the full name(s) of the parent(s)/legal guardian(s) and emergency contact(s) who ARE authorized to sign-in & sign-out your child(ren).

Are there any ADDITIONAL persons (other than parents/legal guardians and emergency contacts) who are authorized to sign-in & sign-out your child(ren)?

Yes

No

N/A, my child will be signing themselves in and out

If you selected YES, please write the full name(s) of the authorized additional persons below AND their relationship to your child(ren). *PLEASE DO NOT FILL THIS IN IF YOUR CHILD(REN) WILL BE SIGNING THEMSELVES IN AND OUT.

If you have indicated that your child(ren) will be signed in & out by an authorized person, please note the authorized person is required to enter the Studio upon drop-off & pick-up to sign our attendance logbook, and may be asked to provide picture I.D.

I understand

ALLERGIES & MEDICAL CONDITIONS- Does(Do) your child(ren) have any allergies and/or medical conditions that the Dreaming Heart Art Studio should be aware of?

Yes

No

If you selected YES, please write your child's(ren's) allergies/medical conditions below, along with any pertinent information (*If your form includes information for more than one child, please specify below which child has an allergy/medical condition).

The Studio requires that all children who are prescribed an epi-pen, inhaler, and/or diabetic monitor carry it with them at all times while at the Studio with NO exceptions.

I understand

The Studio does NOT guarantee a food-free, nut-free, or allergen-free environment.

I understand

You assume all risk as it pertains to your child's(ren's) allergies and medical conditions.

Yes

You expressly grant to the Studio consent to seek emergency medical care for your child(ren) when the Studio is unable to contact you and when waiting for your consent would jeopardize the health and welfare of your child(ren).

Yes, I consent

PHOTO & VIDEO CONSENT FOR MINORS-

Yes, I consent to the following

No, I do not consent to the following

I give my consent to the Dreaming Heart Art Studio to take and use photographs and videos of my child(ren) for any legal use including but not limited to advertising and publicity purposes, as follows: printed publications or materials, posters, brochures, electronic publications, and social media. I hereby waive, release, and forever discharge the Dreaming Heart Art Studio from any and all claims or liability arising from the use of my child’s(ren's) photograph or video for the above purposes.

I understand the following

N/A, I do not consent to photos/videos of my child

Is there any other information you would like to share with us about your child(ren)?

YOUR FULL NAME

TODAY'S DATE

By signing below, you confirm that your are the parent/legal guardian of the child(ren) listed above and that the information in this form is accurate and up to date. If any of the above information changes, please promptly resubmit this form.

The Dreaming Heart
Art Studio

Art classes to soothe the soul!

The Dreaming Heart Art Studio

Art classes to soothe the soul!

The Dreaming Heart
Art Studio