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Participant Name
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Pronouns
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Home Address
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School
*
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Grade
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Are there any physical or mental health concerns we should be aware of?
Parent Name
*
First Name
Last Name
Mobile Phone
*
-
Area Code
Phone Number
E-mail
Emergency Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to Participant
*
Primary Physician/Clinic
This information is requested in the case of a medical emergency.
Optional Demographic Information
Gender Identity
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Transgender Male
Gender Nonconforming
Other
Racial Identity
Black/African American/African
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Indigenous
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Other
Is your family eligible for free or reduced lunch or other forms of public assistance?
Yes
No
I don't know
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Photo / Media Consent
I understand my child's image may be taken by photograph or video while at the studio or other special events. I grant permission for heARTS to publish my or my child's photograph or likeness in promotional publications (print, digital, or video formats) and to the media to promote the organization.
I give consent for photo and media release.
*
Yes
No
Consent for Medical Treatment
As the parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a duly licensed doctor. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.
I give consent for emergency medical treatment.
Yes
No
Release from the Studio
Youth attending heARTS have a wide range of autonomy. Please indicate what level of independence you would like for your child's release from the studio. You are welcome to adjust this option at any time.
Please select from the following release options:
*
I give permission for my child to leave heARTS unaccompanied.
I do not give permission for my child to leave heARTS unaccompanied and will notify heARTS if someone other than a guardian is picking up.
Newsletter
Yes, subscribe me to heARTS' e-mail newsletter.
By signing below, you grant permission for your child to attend programming, events, field trips, and service projects associated with Courageous heARTS. You also agree to hold heARTS harmless for accidents or loss/damage of personal property.
Please sign with your finger or curser in the box below:
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