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