International Charter School of Atlanta Registration Form

Artz for the Harp Registration

Montessori School at Emory (Decatur)
Student's Information
Student's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Ethnicity

Black/ African AmericanWhite/ CaucasionAsian or Pacific IslanderAmerican Indian or Alaska NativeHispanic, Latino or of Spanish OriginOther Not Listed
Household Size
Parent/Guardian Information
Home Number

Area CodePhone Number
Does your child recieve free or reduced lunch?
Cell Number

Area CodePhone Number
E-mail
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does the student have/need a prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by AFTH during the selected school term. In exchange for the acceptance of said child’s candidacy by AFTH, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless AFTH and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against AFTH including all directors, facilitators, assistant instructors and interns, as well as all affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Photo/ Media Release:

I, the undersigned, grant permission to Artz for the Harp and/or its affiliates to use my name and my student's name, picture and/or likeness in any manner and in any media, including the organization’s website: www.artzfortheharp.org- either alone or accompanied by other material.

(To the extent that I intend to in any way limit this grant of permission to any particular use of my or my student's name, picture and/or likeness, such limitation has been set forth below on the lines at the bottom of this release.)

I agree that I will not hold the Artz for the Harp and/or its affiliates, singly or collectively, responsible for any liability resulting from the use of my name, picture and/or likeness in the manner described above.
Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the AFTH . and its affiliates including Directors, facilitators, assistant instructors and interns to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM IN AGREEMENT OF ALL TERMS AND CONDITIONS OF THIS REGISTRATION OF MY CHILD WITH AFTH PROGRAMS.

UPON DELIVERING AN ELECTRONIC SIGNATURE, THIS WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent Name

First NameLast Name

AFTH After School Harp Enrichment Program

Motessori School at Emory AFTH Fall Fee 2022$250.00

Montessori School at Emory AFTH Spring 2023 Fee$250.00

AFTH Registration Fee$25.00

Registration fee covers administration fee and cost of books and supplies for class.

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Artz for the Harp Registration