DCOLOREX STUDENT ENROLLMENT/ EMERGENCY INFORMATION.
STUDENT INFORMATION
First Name______________________________ Last Name___________________________________________
Sex________ Age_____________ Grade _________ School____________________________________________
Address_________________________________________________________________________________________
Phone number. Home _____________________________ Cell_____________________________________________
Email address____________________________________________________________________________________
Allergies________________________________________________________________________________________
Any other Health Issues DColorex should be aware of?___________________________________________________
CONTACT INFORMATION
Mother’s Name___________________________________ Cell___________________________________________
Home Phone #__________________________Email address____________________________________________________
Father’s Name _________________________________ Cell __________________________________________________
Home Phone #_________________________Email address_______________________________________________________
Emergency contact different from Parents ________________________________________________________________
Non Authorized People to pick up the child?____________________________________
PHOTOGRAPHY AND VIDEO AUTORIZATION
I do___ I do not __ consent and authorize DColorex to use or reproduce photography
taken of my child or her/his work for advertising and public purposes. Initials _________
I/We the parent(s , guardian(s) of ________________________________________________________________________________
A participant in the DColorex project for Kids “Art”, an Afterschool program, hereby give my/our approval to his/her participation in the DColorex curriculum.
I/We assume all risk and hazards incidental to such participation, and I/We hereby waive, release, absolve, indemnify and agree to hold harmless DColorex program, the organizer, the instructors and other members.
_______________________________________________________________________
Signature Date
STUDENT INFORMATION
First Name______________________________ Last Name___________________________________________
Sex________ Age_____________ Grade _________ School____________________________________________
Address_________________________________________________________________________________________
Phone number. Home _____________________________ Cell_____________________________________________
Email address____________________________________________________________________________________
Allergies________________________________________________________________________________________
Any other Health Issues DColorex should be aware of?___________________________________________________
CONTACT INFORMATION
Mother’s Name___________________________________ Cell___________________________________________
Home Phone #__________________________Email address____________________________________________________
Father’s Name _________________________________ Cell __________________________________________________
Home Phone #_________________________Email address_______________________________________________________
Emergency contact different from Parents ________________________________________________________________
Non Authorized People to pick up the child?____________________________________
PHOTOGRAPHY AND VIDEO AUTORIZATION
I do___ I do not __ consent and authorize DColorex to use or reproduce photography
taken of my child or her/his work for advertising and public purposes. Initials _________
I/We the parent(s , guardian(s) of ________________________________________________________________________________
A participant in the DColorex project for Kids “Art”, an Afterschool program, hereby give my/our approval to his/her participation in the DColorex curriculum.
I/We assume all risk and hazards incidental to such participation, and I/We hereby waive, release, absolve, indemnify and agree to hold harmless DColorex program, the organizer, the instructors and other members.
_______________________________________________________________________
Signature Date
