Touch the Sky, Queens Kids Live!
Youth Performing Arts Workshop
ACTIVITY RELEASE
I ______________________________________________________________________
PRINT NAME OF PARENT, PARENT SIGN NAME & DATE
give my child _____________________________________________________________
PRINT NAME OF MINOR CHILD
permission to participate in the Queens Lutheran School (QLS)/Roberta Wells Conservatory (RWC) Performing Arts and Cheerleading Program. I understand the inherent risks involved with my child being in this program and accept these risks. By my signature, I hereby release and hold harmless the Queens Lutheran School and Roberta Wells Conservatory including staff members, collaborators, consultants and volunteers from any liability, mishaps, or injury to the child named above except in the case of gross negligence.
I ________________________________________________________________________
PRINT NAME OF PARENT, PARENT SIGN NAME & DATE
also grant permission for Queens Lutheran School, Roberta Wells Conservatory and/or emergency staff to treat my child.
PRINT NAME OF MINOR CHILD
to the best of their ability in case of an accident or emergency.
OFFICE
Rec. / /
Touch the Sky, Queens Kids Live!
Youth Performing Arts Workshop
MODEL RELEASE
I
________________________________________________________________________
PRINT NAME OF PARENT, PARENT SIGN NAME & DATE
Hereby grant to the Queens Lutheran School and Roberta Wells Conservatory and its legal representatives and assigns, the irrevocable and unrestricted right to use and publish photographs and video images of my child
PRINT NAME OF MINOR CHILD
in performing arts and cheerleading activities or in which I may be included, for archival, historical, promotional, editorial and any other legal purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. I hereby release Queens Lutheran School, Roberta Wells Conservatory, the Photographers and Videographers and his/her legal representatives and assigns from all claims and liability relating to said photographs and video. The undersigned shall be responsible for any arbitration liability which may be incurred due to his/her taking legal action against Queens Lutheran School and the Roberta Wells Conservatory, their agents or their representatives.
OFFICE
Rec. / /
Touch the Sky, Queens Kids Live!
REGISTRATION FORM
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STUDENT INFORMATION (please Print)
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Child’s Last Name:
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First:
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Middle:
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NICKNAME
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HEALTH:
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ALLERGIES:
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Birth date:
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Age:
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Sex:
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/ /
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q M
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q F
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Street address:
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Home phone :
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( )
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P.O. box:
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City:
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State:
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ZIP Code:
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School
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Address
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Telephone
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Is there a Participating Sibling/Name?
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PARENT/GUARDIAN AND CLASSES
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Parent/Guardian
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Address (if different):
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Home phone :
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( )
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Will parent/guardian be picking up the student?
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q Yes
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q No
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Who will be picking them up/telephone number?
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Parent Work Phone:
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Parent Cell Phone:
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CLASSES TAKING
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WORKSHOP FEE
FEBRUARY
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WORKSHOP FEE MARCH
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WORKSHOP FEE APRIL
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WORKSHOP FEE MAY/JUNE
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MISC.
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UNIFORM /COSTUMES FEES 1
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UNIFORM /COSTUMES FEES 2
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UNIFORM /COSTUMES FEES 3
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MISC.
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IN CASE OF EMERGENCY
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Name of local friend or relative (not living at same address):
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Relationship to student:
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Home phone no.:
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Work phone no.:
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( )
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The above information is true.
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Patient/Guardian signature
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Date
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Roberta Wells Conservatory at Queens Lutheran
