Spring 2019: Art is Good Medicine: Clay Planter

Personal Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• Cell Phone:
• *

  Are you okay with being photographed for promotional material?

  • Yes
  • No

Emergency Contact

• * Emergency Contact Name
• * Emergency Contact Phone Number
• * Emergency Contact's Relation to Student

Allergies

• * Do you have any allergies?
• If yes, please list:
   characters remaining

• Please choose one of the following that best describes yourself.

  • Patient
  • Survivor
  • Caregiver
  • Family Member

• WAIVER OF LIABILITY:

• In consideration for Emerge Gallery & Art Center making programs available to myself or my child, I hereby release Emerge Gallery & Art Center, its employees, volunteers, instructors, and agents from any and all liability, cost/expense associated with any injury I or my child may sustain while participating in any of the programs and activities. Furthermore, I hereby hold Emerge Gallery and Art Center, its employees, volunteers, instructors, and agents harmless for any damage, loss, or claims to my person, child, or proptery. I assume all risks and full responsibilities on the premises, both known and unkown. In case I cannot be reached in an emergency, I give my permission to the Emerge Gallery & Art Center to select proper emergency care and treatment for my child or myself.

• * By typing in my name below, I agree to the statement above. If under 18 years of age must be signature of Parent or Legal Guardian

Guest Information

You may add a maximum of 4