Student Name *

First Name

Last Name

Parent Name *

First Name

Last Name

Parent Phone *

(###)

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

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Youth who are 6th grade or older may be included in adult-level programs with parental consent and teacher approval. If you wish for your child to be considered for inclusion in an adult-level program, please check here.

Yes, I'd like my child to be considered for inclusion in an adult-level program.

Name of additional person authorized to pick up child from Silverton Arts Associaton (child will not be allowed to leave with any other person without written authorization from parent or guardian)

First Name

Last Name

I am the parent/guardian of the child—who is under 18 years of age—registering for Silverton Arts Association classes. * *

Yes

I hereby waive and release and discharge Silverton Arts Association, owners of premises and Board of Directors and each employee and officers, agents and directors of Silverton Arts Association from all claims, demands, actions, judgments and executions which the undersigned or any of them ever had, now has, or may have, or which may arise, or which any of the undersigned's heirs, executors, administrators or assigns may have or claim to have against Silverton Arts Association or its successors or assigns, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by or arising out of Silverton Arts Programming. I acknowledge that I have read or listened to an explanation of this WAIVER AND RELEASE. *

I agree

IN CASE OF MEDICAL EMERGENCY, I understand every effort will be made to contact parents or guardians of participants. In the event I cannot be reached, I hereby give permission to the physician selected by Silverton Arts Association to administer proper medical treatment for your student. *

I agree