PARENT INFORMATION *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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PARTICIPANT INFORMATION *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Certification *

I certify that I am the parent or legal guardian of the above named Participant. I hereby authorize my minor child named above to attend and participate in the Pavilion of Hope Academy of the Arts (the Academy) including any off-campus Academy activity for which I have registered him/her. I understand that my minor child must obey all established rules and follow the instructions of the people in charge of the Academy. I consent to and understand that the persons in charge of the Academy or agents have the right to dismiss my child who is in their opinion a hazard to the safety and well-being of others, I understand that if my child is sent home under such circumstances, I will be responsible for all associated costs incurred, including the cost of special travel arrangements. By signing this parental consent and liability form, I expressly warrant that my child named above is capable of withstanding both the physical and mental demands associated with the Academy for which s/he is registered. I also expressly assume all risks to my child’s participation in the Academy, whether such risks are known or unknown to me at this time. In recognition of these risks and realities, and in consideration of my child being offered the opportunity to participate in and benefit from the Academy, I agree on behalf of myself and my child to release, waive, and disclaim any and all liabilities of or claims against, Pavilion of Hope, its officers, board members, agents, faculty, employees, and all private persons or organizations Volunteering services without charge to transport, supervise, or chaperone my child while participating in the Academy including, but not limited to any or all liabilities or claims for personal injury, property damage, court costs, attorneys’ fees and interest, however, caused or accrued, as a result of my child participating in the Academy.

I Agree

Media Release *

I hereby give Pavilion of Hope and their legal representatives and assigns, the right and permission to photograph, digitally record, videotape, or audio tape, my above named child while s/he is attending and participating in the Academy occurring on or off Pavilion of Hope’s campus. I further agree that any or all of the material recorded may be used, in any form, in publications, including electronic publications, or in audio-visual presentations, promotional literature, advertising, or in other similar ways, and that such use shall be without payment of fees, royalties, special credit, or other compensation. I understand that all such recordings, in whatever medium, shall remain the property of Pavilion of Hope.

I Agree

Medical Authorization *

I recognize that there may be occasions where the minor child named above, may be in need of first aid or emergency medical or dental treatment as a result of an accident, illness, or other health condition or injury. Therefore, I authorize any Pavilion of Hope Staff Member, or Adult Volunteer, in whose care the minor child has been entrusted, to consent to any X-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the provisions of the Medical Practice Act by the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment. As parent or legal guardian of my minor child (Participant named above), I am responsible for the health care decisions of my minor child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for dental, medical, and/or hospital care or treatment to be rendered to my minor child is legally sufficient and that no consent from any other person is required. By signing below, I authorize any Pavilion of Hope Staff Member or Adult Volunteer, in whose care the minor child has been entrusted to authorize any hospital or physician or other health care provider to bill the following insurance company or companies for the payment of any services rendered to the minor child. I agree to assume responsibility for the charges for such care as rendered to the above named minor child. I authorize any hospital, physician, or other health care provider to release information from the minor child's medical record to the insurance company named below, in connection with the completion of any insurance claim form. I have read, understood and agreed to the information above. All releases, authorizations and permission granted above shall remain in effect unless revoked in writing by the undersigned to Pavilion of Hope, 3558 East Ponce de Leon Avenue, Scottdale, Georgia 30079.

I Agree