Full Student Name
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First Name
Last Name
Parent/Guardian Name
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First Name
Last Name
Primary Emergency Contact Phone
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This is the first phone number we will contact in the case of a question or emergency.
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Secondary Emergency Contact Phone
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This is the second phone number we will contact in the case of a question or emergency and we cannot get ahold of the primary phone number.
(###)
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Home Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Allergies/Special Health Considerations
This information is only shared with the instructor if necessary and otherwise kept confidential.
Infectious Disease: Assumption of Risk, Release, and Waiver of Liability
I understand that while Foci MCGA has undertaken reasonable steps to lessen the risk of transmission of COVID-19 and other infectious disease, and that Foci MCGA is not responsible in any manner for any risks related to COVID-19 in connection with their services. I understand that the World Health Organization has classified the COVID-19 outbreak as a pandemic. I further understand that COVID-19 is a highly contagious and dangerous disease, and that contact with the virus that causes COVID-19 may result in significant personal injury or death. I am fully aware that participation in the Services (including any related travel) carries with it certain inherent risks related to COVID-19 transmission (“Inherent Risks”) that cannot be eliminated regardless of the care taken to avoid such risks. Inherent Risks may include, but are not limited to, (1) the risk of coming into close contact with individuals or objects that may be carrying COVID-19; (2) the risk of transmitting or contracting COVID-19, directly or indirectly, to or from other individuals; and (3) injuries and complications ranging in severity from minor to catastrophic, including death, resulting directly or indirectly from COVID-19 or the treatment thereof. Further, I understand that the risks of COVID-19 are not fully understood, and that contact with, or transmission of, COVID-19 may result in risks including but not limited to loss, personal injury, sickness, death, damage, and expense, the exact nature of which are not currently ascertainable, and all of which are to be considered Inherent Risks.
I hereby voluntarily accept and assume all risk of loss, personal injury, sickness, death, damage, and expense arising from such Inherent Risks. Furthermore, I represent and warrant that I do not suffer from any medical condition or disease that might in any way hinder or prevent me from receiving Foci MCGA's services, including, to my knowledge, COVID-19.
I expressly agree that this Agreement is intended to be as broad and inclusive as is permitted by applicable laws, and that if any portion of this Agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. This Agreement contains the entire understanding of the parties relating to the subject matter, and shall not be altered, modified, amended, waived or supplemented in any manner whatsoever except by a written agreement signed by both parties hereto or their duly authorized representatives. To the maximum extent permitted by applicable law, I (a) covenant and agree not to elect a trial by jury with respect to any issue arising out of this Agreement or the Services that is triable of right by a jury, and (b) waive any right to trial by jury with respect to such issue to the extent that any such right exists now or in the future. This waiver of right to trial by jury is given knowingly and voluntarily. I have read and understood this Agreement and enter into it voluntarily in consideration of the opportunity to participate in the Services. I acknowledge I am giving up legal rights and/or remedies which may be available to me.
REQUIRED: Photo & Video Release
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Occasionally our nonprofit organization takes photos or videos of students to be used promotionally for our glass art programming and grantwriting. Images may be taken of your minor working in a group setting or of their glass art projects. Parent/guardian waives all claims for remuneration for said use whether based on invasion of privacy or any other reason.
Please reach out to us directly at contact@mnglassart.org if you would like to arrange for no photos to be taken of your minor.
REQUIRED: I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
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Response is required to complete and submit form.
REQUIRED: I have carefully read and agree to the terms of this Release & Indemnity Agreement and know the contents thereof, and I sign the same as my own free act. I release Foci MCGA and individuals from liability in case of accident during activities related to Foci MCGA, as long as normal safety procedures have been taken.
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By typing your name you are consenting to e-signatures.
First Name
Last Name
How did you find out about Foci MCGA?
Your response is not required but appreciated.
