All Forms

Pick-Up Authorization Form

Medical Authorization to Treat Form

General Release Form

Pick-Up Authorization Form

General Information
Program Name*
Start Date*
Date Format: MM slash DD slash YYYY
Time(s)*
Day(s) of the week and Time(s) Example: MWF 9:00AM-3:00PM
Participant's Name*
Parent/Legal Guardian Name*
Parent/Guardian Phone Number*
Please fill out either Section I or II.
SECTION I
Please list any individual who is authorized to pick up the Participant, including yourself. Each authorized person must be at least 16 years of age. The above-named Participant will not be permitted to leave the Program with anyone who is not listed below. Authorized individuals must pick up Participants in person and may be requested to show identification to Program staff when picking up a Participant. Participants will not be released to persons who fail to provide acceptable identification upon request.

I authorize the following responsible person to pick up the Participant from the aforementioned Program activities:

Include Parents - You can add up to 4 Authorized Persons. Add or Remove by selecting the plus/minus buttons.

Authorized Person	Phone Number	Relationship to Child

The following individuals are not permitted to pick up the Participant:

Include Parents - You can add up to 4 Authorized Persons. Add or Remove by selecting the plus/minus buttons.

Unauthorized Person	Brief Description	Relationship to Child

SECTION II
The Participant is at least 16 years of age and will be responsible for his/her own transportation to and from Program. The Participant may sign him/herself in at the start of Program activities and sign him/herself out at the end of Program activities.
Correct Section*
I Agree that all stated above is correct*
- Yes
Name
First Last
Signature*

Medical Authorization to Treat Form

EMERGENCY MEDICAL AUTHORIZATION TO TREAT
Center for the Arts requests the following information so that the program staff can arrange for medical care in the event of an emergency. You are responsible for providing accurate and complete information.
Camp Name*
Start Date*
Date Format: MM slash DD slash YYYY
Location*
General Information
Participant's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone*
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Insurance Information
Do you have health/accident insurance?*
Company Name*
Company Address*
Policy Number*
Group Number*
Health Information
Is the participant on medication or under treatment on a continuing basis?*
If applicable, please describe*
Allergies
Does the participant have any allergies we should be aware of?*
If applicable, please describe*
Vaccination Information
Date of last Tetanus vaccination*
Date Format: MM slash DD slash YYYY
EMERGENCY CONTACT INFORMATION
Please list emergency contacts who may be contacted in case of emergency involving your child. Each person listed should be reachable by telephone and able to make decisions on behalf of your child if a parent and legal guardian cannot be reached. If necessary, an emergency contact should be able to come to the Program site and pick up your child.
Emergency Contact #1 Name*
Home Phone*
Work Phone*
Cell Phone*
Relation*
Emergency Contact #2 Name*
Home Phone*
Work Phone*
Cell Phone*
Relation*
AUTHORIZATION FOR MEDICAL CARE
To the best of my knowledge, my child/participant is capable of participating safely in the Program and that any activity restrictions, allergies, and medications are listed on this form.

I give my permission to Program staff to provide routine first aid care and in the event of serious illness or injury, I give Program staff permission to seek and authorize emergency medical treatment. I agree to indemnify and hold harmless Center for the Arts of Greater Manassas/Prince William County, Inc. and their officers, employees and agents, from any claim, damage, liability, injury, expense, or loss, including defense costs and attorney's fees, arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my child that may occur during his/her participation in this Program.

I understand and acknowledge that my failure to disclose relevant information may result in harm to Participant and/or others during this Program. By signing my name, I represent that I have provided all materials and important information to the Program pertaining to Participant's medical, mental and physical condition and that it is accurate and complete. I agree to notify the Program of any changes in mental, physical or medical condition before the Program begins.
Parent/Legal Guardian Name*
Email*

Add Another Parent/Legal Guardian

Parent/Legal Guardian Name	Phone	Email

Date
Date Format: MM slash DD slash YYYY
Name
First Last
I understand by signing this form that I have read and agree to the Authorization for Medical Care Terms and Conditions*
- I understand
Signature*

General Release Form

CENTER FOR THE ARTS
PHOTO, AUDIO, VIDEO AND COMMENT RELEASE FOR SUBJECTS UNDER 18
Camp*
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
This form is for a*
GENERAL RELEASE
I hereby grant permission to Center for the Arts of Greater Manassas/Prince William County, Inc. the absolute and irrevocable right and permission, with respect to photographs, videos, and audio recordings taken or made of and/or comments made by the above-named student or in which the student may be included with others; to use, re-use, and publish the same in whole or in part in any and all media including use on the world wide web, now or hereafter, and for any purpose whatsoever for illustration, promotion, art, recruitment, publication, advertising, and trade, and if appropriate, to use the student’s name and pertinent education and/or biographical facts as the Center chooses. Use of photographs, videos, comments, and audio recordings is granted without any restriction as to changes or alterations (including but not limited to composite or distorted representations or derivative works made in any medium) and I waive any right to inspect or approve the finished versions incorporating the photograph, video, audio recording, and/or comments including written copy that may be created and appear in connection therewith.

I agree that the Center owns the copyright in these photographs, videos, and/or audio recordings and I hereby waive any claims I may have based on any usage of the works derived therefrom. I hereby fully and forever discharge and release the Center and its employees, agents, assigns, licensees, successor in interest, and legal representatives from any claim for damages or claims of any kind (including, but not limited to, invasion of privacy; defamation; false light or misappropriation of name, likeness or image) or any other cause of action arising out of the use or publication, distribution, modification and exhibition of photographs, videos, audio recordings, and/or comments by the Center, and covenant and agree not to sue or otherwise initiate legal proceedings against the Center. The photographs, videos, audio recordings, and/or comments will not be sold to any other firm or organization.

I am not a minor and have the right to contract in my own name and the name of the above-named student. I have read the foregoing and fully understand its contents. This release shall be binding on me and my heirs, legal representatives, and assigns.
GENERAL RELEASE
I am the Parent/Guardian of the above-named student who is under eighteen years of age and am fully competent to sign this release. I hereby grant permission to Center for the Arts of Greater Manassas/Prince William County Inc. the absolute and irrevocable right and permission, with respect to photographs, videos, and audio recordings taken or made of and/or comments made by the above-named student or in which the student may be included with others; to use, re-use, and publish the same in whole or in part in any and all media including use on the world wide web, now or hereafter, and for any purpose whatsoever for illustration, promotion, art, recruitment, publication, advertising, and trade, and if appropriate, to use the student’s name and pertinent education and/or biographical facts as the Center chooses. Use of photographs, videos, comments, and audio recordings is granted without any restriction as to changes or alterations (including but not limited to composite or distorted representations or derivative works made in any medium) and I waive any right to inspect or approve the finished versions incorporating the photograph, video, audio recording, and/or comments including written copy that may be created and appear in connection therewith.

I agree that the Center owns the copyright in these photographs, videos, and/or audio recordings and I hereby waive any claims I may have based on any usage of the works derived therefrom. I hereby fully and forever discharge and release the Center and its employees, agents, assigns, licensees, successor in interest, and legal representatives from any claim for damages or claims of any kind (including, but not limited to, invasion of privacy; defamation; false light or misappropriation of name, likeness or image) or any other cause of action arising out of the use or publication, distribution, modification and exhibition of photographs, videos, audio recordings, and/or comments by the Center, and covenant and agree not to sue or otherwise initiate legal proceedings against the Center. The photographs, videos, audio recordings, and/or comments will not be sold to any other firm or organization.

I am not a minor and have the right to contract in my own name and the name of the above-named student. I have read the foregoing and fully understand its contents. This release shall be binding on me and my heirs, legal representatives, and assigns.
I understand by signing this form that I have read and agree to the terms presented in the Terms and Conditions agreement*
- I understand
Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Signature*

All Forms

All Forms

Pick-Up Authorization Form

General Information

Please fill out either Section I or II.

SECTION I

SECTION II

Medical Authorization to Treat Form

EMERGENCY MEDICAL AUTHORIZATION TO TREAT

General Information

Insurance Information

Health Information

Allergies

Vaccination Information

EMERGENCY CONTACT INFORMATION

AUTHORIZATION FOR MEDICAL CARE

General Release Form

CENTER FOR THE ARTS

GENERAL RELEASE

GENERAL RELEASE