Authorize Payment Form Summer Evening Workshops

Summer Evening Workshops Registration:
How did you hear about us? *
Parent/Legal Guardian *

First Name Last Name
E-mail *
Phone Number *

Area Code Phone Number
Emergency Contact *

First Name Last Name
Emergency Contact Phone # *

Area Code Phone Number
Number of Children *
How many Kids are you Registering?
Child's name (1) *

First Name Last Name
Childs Birth Date (1) *

Month Day Year
Child's name (2)

First Name Last Name
Childs Birth Date (2)

Month Day Year
Child's name (3)

First Name Last Name
Childs Birth Date (3)

Month Day Year
Person authorized to drop off and pick up your children

First Name Last Name
Medical and behavioral conditions
Please list any allergies and /or any medical or behavioral conditions (add name of child if more than one)
A bit more info and you will be done! Click next and select your Camp/Dates.

Camps *

SUMMER EVENING WORKSHOPS

Select Workshop	Price	Quantity
Sticker Making - digital and traditional	$ 75.00
Blender: 3D Modeling & Animation	$ 110.00
Anatomy and drawing skill development	$ 115.00
Batiks: traditional textile craft	$ 190.00
Kids Night Out Pin Making (digital and traditional)	$ 55.00

Item subtotal: $ 0.00

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Total $ 0.00

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Expiration Month	Expiration Year
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PERMISSION / AUTHORIZATION
I hereby authorize/consent myself, my child(ren) and/or my child(ren)'s caregiver to participate in Little Blank Canvas activities, except as noted below:
I grant permission for the staff at Little Blank Canvas to take any and all necessary steps to obtain emergency medical care for my child(ren), if warranted in their sole discretion, and agree that any expenses associated with any medical care will be my responsibility. In all cases of emergency, the child's welfare will be the primary focus; however, every reasonable attempt will be made to immediately reach the Parent/Guardian or designated caregiver. These steps may include, but are not limited to, the following:
• Administering first aid and Calling an ambulance or paramedics
List activities in which you specifically do not wish your child(ren) to participate
ASSUMPTION OF RISK, RELEASE, WAIVER AND INDEMNIFICATION
I hereby acknowledge, agree, and accept the risk of injury inherent in any physical activity or program, including particularly, the activities offered by Little Blank Canvas. Such risks may include but are not limited to falling, bumping, risks from abrasions, scrapes, cuts, broken, sprained or bruised limbs, injury to eyes, consumption or inhalation of paint or other media, as well as risks from the actions or omissions of others.
As such, I hereby release, discharge, indemnify and hold harmless Little Blank Canvas, its owners, members, managers, instructors, affiliates, agents, employees, successors and assigns, from any and all injuries, illnesses, medical conditions, medical care, death, damages, claims, liabilities, expenses or judgments, including attorneys’ fees and court costs resulting from my, my child(ren)'s, or my child(ren)'s caregiver’s participation in a program or presence on Little Blank Canvas premises or other location where Little Blank Canvas may conduct art instruction, except as such may arise out of Little Blank Canvas's gross negligence.
I expressly agree that Little Blank Canvas may use photos, video, sound recordings taken of me and my child(ren), for any purpose, including use for publicity. In addition, I agree that Little Blank Canvas shall have a fully-paid, perpetual license to use photographs, copies or reproductions of any work of art produced in its studio by me or my child(ren).
I hereby release Little Blank Canvas from any damage or loss to any of my personal property.
I understand and agree to all of the terms of this Permission Form and all questions that I may have had related to this Form have been answered to my satisfaction, and I understand that this constitutes a waiver and release of liability of Little Blank Canvas. I acknowledge receipt of and agree to the Little Blank Canvas policies.
Signature *

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Summer Evening Workshops Registration: