Molasky MS - Symbolic Art

**PROGRAM REGISTRATION FORM *MOLASKY MS**
Please Note: "Required" fields followed by an asterisk must be filled in

* Indicates required field

Insert Child's Name *

First

Last

DATE OF BIRTH *

Name of School *

Insert The Name(s) of Sibling(s) "N/A" if Not Applicable *

NAME OF SIBLING'S SCHOOL "N/A" IF NOT APPLICABLE *

Sibling(s) & Date of Birth N/A if Not Applicable *

Allergies or Special Needs? N/A if not applicable *

Enrolling Parent or Guardian's Name *

First

Last

Enrolling Parent's Email *

Enrolling Parent's Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Insert Work Phone *

Insert The Name & Phone Number To Receive Text Messages *

Insert Emergency Contact Information *Include: Name, Relationship & Phone Number *

Insert Name(s) of anyone other than parent, guardian or emergency contact who may pick up Child(ren) *

How Did You Hear About Symbolic Art @Molasky? *

Last Symbolic Art Event Attended *

Fee Disclosure*

An 'annual' registration fee: $25 is required for each new participant enrolled in Symbolic Art programs; Symbolic Art fees can be made: Daily, Weekly or Monthly *Symbolic Art participants are eligible to attend "Free" workshops throughout the week. *Enrollment fees are non-refundable in the event participant is absent from the program. Payments may be made in cash, money order, Paypal or credit card. Payments will only be accepted from adults listed on this form.A $10 late fee will be assessed for each :15 minutes past 6:30 p.m. (e.g. 6:45 pm / pick up = +$10)

AGREE & CONSENT *

I UNDERSTAND THE ABOVE & CONSENT

Sign-In & Sign-Out

To protect the safety of our children I understand each child must be signed in and out daily. The only person(s) authorized to pick up the child(ren) are those listed on this form; photo ID must be shown.

AGREE & CONSENT *

I UNDERSTAND THE ABOVE & CONSENT

Children "will not" be released without proper identification "and" prior written authorization from enrolling parent/guardian. *Authorization via Email is acceptable

AGREE AND CONSENT *

I UNDERSTAND THE ABOVE & CONSENT

In the case of joint custody disputes - Symbolic Art staff will comply "Only" with "Written" instructions directed by court order on file with Symbolic Art (if applicable)

AGREE & CONSENT *

I UNDERSTAND THE ABOVE & CONSENT

Waiver of Claim*

For ourselves, and/or on behalf of our child named above, our heirs, affiliates, executors, and administrators, we hereby do expressly and forever waive and release Symbolic Art Central, Inc dba, "Symbolic Art" and their respective officers, employees, agents or representatives from any and all liability for personal injury or damages, sustained, incurred, arising from or connected with travel to, return from any and all classes, tournaments and/or special events, and all activities related to, or in connection with said activity by ourselves or by our child. *Symbolic Art is a community based organization focused on making sports, recreation and artistic expression fun for youth ages 4-14. During programs or events Symbolic Art staff may take photos of participants that may be used in professionally designed publications, websites, promotional materials and social media platforms.

AGREE & CONSENT *

I UNDERSTAND THE ABOVE & CONSENT

Parent Letter*

I have received, read and understand the contents of the parent letter

AGREE & CONSENT *

I UNDERSTAND THE ABOVE & CONSENT

Please Type Your Name Acknowledging You
Accept Symbolic Art Terms & Conditions*

Name *

First

Last

SUBMIT REGISTRATION FORM