GiftedImpact Enrollment Enrollment Form GiftedImpact Enrollment Form Student Name * First Name Last Name Date of Birth * MM DD YYYY School Site * Barwell Road Elementary Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Grade T-Shirt Size * Youth S Adult S Adult M Adult XL Adult 2XL Please explain any of your child's special needs? Background/Ethnicity * Asian/Pacific Islander Black/African-American Caucasian/White Latin/Hispanic Origin Native American/American Indian Parent/Guardian Information Primary Parent/ Guardian * First Name Last Name Relationship to child * Does child live with this individual? * Yes No Part-time Email * Preferred method of contact: * Home phone Cell phone Email Text Parent Phone * (###) ### #### Does your child have allergies, special diets, or medications? * Yes No If yes, please list/describe: Does your child have any additional needs? * Yes No If yes, please describe: Does your child have any serious medical conditions? * Yes No If yes, please describe: Emergency Contact Information The emergency contact should not be the same as primary parent/guardian. Emergency Contact Name 1 * First Name Last Name Emergency Contact Phone 1 * (###) ### #### Do you give permission for your child to be released to this person? * Yes No Parent Consent/Release Form I certify that my child who is hereby enrolled in TheGifted Arts, Inc. with this agreement, is in excellent health and may participate in the physical activities associated with the TheGifted Arts Program. I represent that my child has insurance through my own or an alternative insurance carrier. I understand that each participant must assume the risk and related financial responsibility that could result from participation in any activities. I agree to assume any risk and financial responsibility. * Agree Disagree Pictures / Media (Please check one) * Do you grant permission to TheGifted Arts, Inc. to use pictures and video(s) of your child in any promotional material, as well as to post on TheGifted Arts Inc. website and/or social media outlets. I grant Permission I DO NOT grant Permission Data /Surveys (Please check one) * We are seeking permission to occasionally survey enrolled members to measure student growth and program satisfaction. I grant permission I DO NOT grant permission Thank you! Your enrollment form has been received. You should receive a confirmation email shortly.
