Student InformationStudents First Name*Nickname if PreferredStudent's Last Name*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Grade as of Spring 2021*1st2ndSchool*Example: Homeschool, Stockwell Elementary, Sharon Elementary, etc.Gender*GirlBoyChurch Attended (if any)Class Options 4:00PM-5:00PMFirst Choice:*Painting & DrawingHip Hop DanceSecond Choice:*Hip Hop DancePainting & DrawingSelect a different option than First ChoiceClass Options 5:00PM-6:00PMFirst Choice:*Comic & Cartoon DrawingActingSecond Choice:*Comic & Cartoon DrawingActingSelect a different option than First ChoiceParent/Guardian InformationParent/Legal Guardian's Name* First Last Parent/Legal Guardian's Relationship to Child*Parent/Legal Guardian's Cell Phone*Parent/Legal Guardian's Home Phone*Additional Parent/Legal Guardian's Name First Last Additional Parent/Legal Guardian's Relationship to ChildAdditional Parent/Legal Guardian's Cell PhoneAdditional Parent/Legal Guardian's Home PhoneEmergency Contact (Other than the names listed above)* First Last Emergency Contact Phone*List all people, INCLUDING YOURSELF, approved to pick up your child*Child's Health InformationFood Allergy*YesNoIf yes, please list specific food allergiesList Any Other Medical Conditions (asthma, etc.) or Activity RestrictionsAre all child's shots current*YesNoIf no, please explainPAYMENTThe payment for Foundry After School Arts Program will consist of 4 payments of $40 for the full 16 weeks. You must submit your online registration by January 11, 2021 to secure your child’s spot. A separate registration form must be filled out for each student you are registering. You may cancel at any time with written notification 2 weeks prior to next payment.RELEASE AND INDEMNIFICATION AGREEMENTConsent* I agree to the Foundry Center for the Arts Release and Indemnification Agreement.(I) (We) the undersigned, parent(s)/guardian(s) of the registrant above, a minor, do hereby acknowledge my child's participation in the Foundry Center for the Arts programming. I am fully aware that my child’s (or children’s) participation in any Foundry programming is totally voluntary. In consideration of the Foundry Center for the Arts I agree to permit my child(ren) to participate in the aforementioned lessons/activities, the receipt and sufficiency in which consideration is hereby acknowledged, I agree as follows: 1) I, individually, and on behalf of my minor child (or children) and our respective heirs, successors, assigns and personal representatives, hereby release, acquit and forever discharge the Foundry Center for the Arts and their teaching artists and assistant teaching artists, students, volunteers, board members, officers, trustees and representatives (in their official and individual capacities) from any and all liability whatsoever for any and all damages, losses or injuries, including death, to persons or property or both, including but not limited to any claims, demands, actions, causes of action, damages, costs, expenses and attorneys fees, which arise out of, during or in connection with my child’s (or children’s) participation in the aforementioned lessons and activities, including but not limited to any damages, losses, or injuries to persons or property or both, which may be sustained or suffered by my child or any person in connection with my child’s (or children’s) association with, or participation in, activities at, sponsored by, or arising out of the Foundry Center for the Arts activities and meetings. 2) I agree that this Waiver, Release and Indemnification Agreement is intended to be as broad and inclusive as permitted by the laws of the state of Indiana, and if any portion hereof is held invalid, it is agreed that the balance hereof shall, notwithstanding, continue in full legal force and effect. 3) I hereby consent to any publicity, including the use of my child’s name and likeness in connection with my child’s participation in the Foundry Center for the Arts lessons and activities. 4) In signing this Waiver, Release and Indemnification Agreement, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provision, that I understand it affects my legal rights and those of my child (or children), that it is a binding Agreement, and that I have signed it knowingly and voluntarily. By typing my name below, I am signing this agreement.Electronic Signature*Date* Date Format: MM slash DD slash YYYY CHILD'S MEDICAL CONSENTConsent I agree to the Foundry Center for the Arts Child's Medical Consent.(I) (We) the undersigned, parent(s)/guardian(s) of the registrant above, a minor, do hereby authorize the adult sponsors of the Foundry Center for the Arts, as agent(s) for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, which is deemed advisable by, and is required to be rendered under the general or special supervision of, any physician or at the hospital or other health care facility only during the hours of the Foundry Center for the Arts programming. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of the aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which may be determined by a physician or surgeon, as aforesaid, to be advisable in the exercise of his/her best judgement. By typing my name below, I am signing this agreement.Electronic Signature*Date* Date Format: MM slash DD slash YYYY MEDIA RELEASE NOTICEConsent I agree to the Foundry Center for the Arts Media Release Notice.This notice serves to announce that filming, taping, and or photography will take place during the Foundry Center for the Arts programming. By entering our partner location, you grant the Foundry Center for the Arts the right to photograph you and your dependent children, to record your voice and to use your likeness without compensation. You also agree to release the Foundry Center for the Arts from any liability in connection with the taping/video production in perpetuity. Video and still images produced from Foundry program activities may be used by The Foundry Center for the Arts in print publications (e.g. flyers, brochures) or video productions. Video and still images may be posted to the Foundry Center for the Arts website and social media pages. By entering the Foundry Center for the Arts partner locations, you agree to allow your image to be used for these purposes. By typing my name below, I am signing this agreement.Electronic Signature*Date* Date Format: MM slash DD slash YYYY Almost Done...
