Student's Name: *

First Name

Last Name

Date of Birth: *

MM

DD

YYYY

Parent/Guardian 1: *

First Name

Last Name

Primary Phone Contact: *

(###)

###

####

Parent/Guardian 2:

First Name

Last Name

Phone:

(###)

###

####

Mailing Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency contact name (other than parent/guardian) *

First Name

Last Name

Emergency contact phone: *

(###)

###

####

Physician's phone number: *

(###)

###

####

Emergency Waiver (required) *

Emergency: I hereby authorize and request MCMA staff to provide or secure necessary emergency treatment for my child should the need arise. I give permission for my son/daughter to receive emergency treatment at a hospital and/or from a licensed physician. I further understand that I will be contacted immediately if any emergencies arise. If I cannot be reached, I give permission for MCMA staff to reach out to the Emergency Contact listed above.

I agree

I do not agree

Media Permission (required) *

Any photographs or videos taken of my child may be used for publicity purposes on our marketing materials, social media, and/or website. Students, if identified, will be identified on a first name basis only.

I agree

I do not agree

Participation agreement (required) *

I give permission for my son/daughter to participate in all summer program activities both within our studio and outside the studio. Outside activities may include walking field trips to a hiking trail, nearby parks for lunch, etc.

I agree

I do not agree

Today's date: *

MM

DD

YYYY