Student's Information Student's Name *
Student's Grade Level * Grade Level 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade Student's Gender * Student's Gender Female Male Prefer Not to Answer Race/Ethnicity * Race/Ethnicity Caucasian African-American Latino or Hispanic Asian Native American Native Hawaiian or Pacific Islander Two or more Other/Unknown Prefer not to say SNAP Participant? * Student's Address
* Parent/Guardian's Information Parent/Guardian's Name *
Emergency Information Emergency Contact's Name *
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe. * Is the student prescribed any medications? If yes, please explain any instructions. * Immunizations: Please provide a copy of the student's immunization records. If you do not have immunization records for the student, please explain: * Please list the name(s) of person(s) authorized to pick up the student from the program: * Photography/Media Acknowledgment Photography/Media Acknowledgment *
I hereby grant the Rockford Area Arts Council permission to use my student’s likeness and/or artwork in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.
I understand and agree that all photos will become the property of the Rockford Area Arts Council and will not be returned.
I hereby irrevocably authorize the Rockford Area Arts Council to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my student’s likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.
I hereby hold harmless, release, and forever discharge the Rockford Area Arts Council from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I HAVE READ, UNDERSTAND, AND ACCEPT THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE. Informed Consent and Acknowledgment *
I hereby give my approval for my child’s participation in any and all activities prepared by the Rockford Area Arts Council during the selected camp. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Rockford Area Arts Council 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.
I hereby hold harmless, release, and forever discharge the Rockford Area Arts Council from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
In case of injury to said child, I hereby waive all claims against the Rockford Area Arts Council including all teachers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. 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 student. 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 Rockford Area Arts Council and its affiliates including Directors, Teachers, and Facilitators to provide the needed emergency treatment prior to the child’s admission to the medical facility.
I hereby hold harmless, release, and forever discharge the Rockford Area Arts Council from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. Release authorized on the dates and/or duration of the registered program. * 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.