Child's name *

First Name

Last Name

Child's DOB *

MM

DD

YYYY

Parent/Guardian 1 *

First Name

Last Name

Phone *

(###)

###

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Parent/Guardian 2

First Name

Last Name

Phone

(###)

###

####

Authorized Adult for Pickup (other than those listed above)

First Name

Last Name

Phone

(###)

###

####

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Child's Physician *

First Name

Last Name

Phone *

(###)

###

####

Consent for Medical Treatment: In the case of medical emergency, I understand that every reasonable attempt will be made to contact the Parent(s)/Guardian(s) or another designated emergency contact. However, in the event that I cannot be reached, I give my permission to the Educators to help my Child and secure emergency medical treatment. I agree to pay for any charges for emergency medical treatment that are not covered by my personal health insurance. This acknowledgement and consent applies for the duration in which my child attends class. * *

I have read, understand, agree to the terms of the 'Consent for Medical Treatment' above.

Acknowledgement of Risk: I acknowledge that there are risks inherent in any youth activity, including – but not limited to – injury arising from participation in outdoor physical activity. I acknowledge that all risks cannot be prevented, and assume those beyond the reasonable control of the teachers and staff. In consideration of being permitted to participate in Forest Poetry by The Write Space, LLC, on behalf of myself, my family, my heirs, and my assigns, I hereby release and hold harmless The Write Space, LLC, its teachers and its staff from any liability for injury, loss, or death to the Child. In order to minimize risks to my Child and others, I will take responsibility to make sure that my Child is prepared for all activities, dressed appropriately for the weather, and is in good health for each class. * *

I have read, understand and agree to the terms of the 'Acknowledgement of Risk' above.

Consent to Photograph: I do hereby consent and agree that The Write Space, LLC has the right to take photographs and video clips of my child and to use these on the Educator's websites and promotional materials without compensation. Your child's name and identity will not be revealed.

I have read, understand and agree to the terms of the 'Media Release' above.