Child's Name *

First Name

Last Name

Parent's Name *

First Name

Last Name

Phone *

(###)

###

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Emergency/ Alternate contact *

First Name

Last Name

Emergency/ Alternate Phone *

(###)

###

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I understand that if my minor child (the student) becomes ill or injured, the instructors at Linda Jones Studio will direct them to be taken to a physician as the situation or occurrence may require. I assume all financial responsibility and waive all claims or future claims against Rebecca Jones, Linda Jones or Linda Jones Art Studio, its owners, their family members, employees, their family members, agents, program participants and anyone else acting in any capacity on their behalf for any illness or injury sustained by the above- named participant. I, the undersigned, have read this medical authorization consent form and declare and affirm consent to the content herein stated. *

Yes, I agree

Photo Release: I give consent for my child’s picture to be taken and used by Rebecca or Linda in promotion of art events: *

Yes

No