Emergency and Permissions Form

Please complete and submit this form prior to any minor student starting a session that will have him or her with us for more than four consecutive hours.

Student Name*

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Date of Birth (MM/DD/YY)*

Email Address of Parent or Guardian*

Email is our primary form of communication, so please use an address that you check frequently.

Emergency Contacts

Please list the person completing this form as Emergency Contact 1 below.

Emergency Contact 1: Full Name*

Emergency Contact 1: Relation to Student*

Emergency Contact 1: Phone Number*

Emergency Contact 2: Full Name*

Emergency Contact 2: Relation to Student*

Emergency Contact 2: Phone Number*

Medical Provider

Physician Name

Physician Phone Number

Insurance Carrier

Insurance Policy Number

Insurance Group Number

Medical History

Allergies

Medications currently being taken

Anything else we should know

Emergency Medical Release*

Yes
No

In case of emergency, I understand that every effort will be made to contact the parents or guardians. In the event that I cannot be reached, I give permission to the physician selected by the Arts Council of Princeton to hospitalize, secure proper treatment for, and to order anesthesia or surgery for my child. I understand I am financially responsible for any expense for medical care or transportation incurred on my child’s behalf. I hereby release the Arts Council of Princeton and its employees from any responsibility for injuries or illness occurring as a result of, or coincidental to, my child’s participation in this program.

Permissions

Walking Field Trip Permission*

Yes
No

I give permission for my child to participate in walking field trips within walking distance from the Paul Robeson Center. I understand that students will be supervised at all times by one or two adults, depending on the class size. With supervision, younger children are taken to the YMCA playground, and preteens/teens are taken to the Princeton University Art Museum and the Princeton Farmer’s Market on Thursdays.

Self-Dismissal*

Yes
No

I give permission for the student listed above to be dismissed in his or her own at the end of the day.

Please list the names and telephone numbers of all the people you authorize to pick-up the student listed above:

Photographic Image Permission*

I give permission for the student listed above to appear in photos/videos as described below.
I have read the statement below and will email my disconsent to info@artscouncilofprinceton.org

The Arts Council of Princeton uses photographic and video images (without student names or identifiers) of classes, workshops, and events in various publications ranging from our website and newspaper articles to grant applications and annual reports. It is a vital way for us to convey the importance of our work in the community. If you do not want your or your child’s photo used by the Arts Council of Princeton, you must notify us in writing (by email to info@artscouncilofprinceton.org or by postal mail) prior to attendance in the program.

Is your child assigned an aide in school? *Voluntary response, but helps us prepare*

Please complete and submit this form prior to any minor student starting a session that will have him or her with us for more than four consecutive hours.

Emergency Contacts

Medical Provider

Medical History

Permissions