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 Name of Student (s):


Date of Birth:


Parent (s) / Guardian (s):




City, State, and Zip:




Phone (Home/work):


Cell / Pager:


Emergency Contact and Phone:


Special Health Care Needs:



RELEASE AND WAIVER: As the parent or legal guardian of the above child, who is a minor child under the age of eighteen (18) (hereinafter “my Child”), and in exchange for the benefits to be derived by my Child’s participation in the Arts Corner’s field trip, I hereby agree, on behalf of myself and my child, to the following:


I hereby grant my permission for my Child to participate in the field trip (hereinafter “the Activity”). I am fully aware of the risks and hazards connected with my Child’s participation in the Activity, and hereby elect to allow my Child to voluntarily participate in the Activity, knowing that the Activity may be hazardous to my Child or to his or her property. On behalf of myself and my Child, I VOLUNTARILY ASSUME ALL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, that may be sustained by my Child, or any loss or damage to property owned by myself or my Child, as a result of my Child being engaged in the Activity, WHETHER CAUSED BY THE NEGLIGENCE OF THE ORGANIZATION OR ITS VOLUNTEERS, AGENTS, or otherwise. On behalf of myself and my Child, as well as our respective estates, heirs, administrators, executors, and assigns, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE The Arts Corner, their officers, servants, agents, employees, or volunteers (hereinafter “RELEASEES”) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, that may be sustained by me, or my Child, to any property belonging to me or my Child, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES or otherwise, while participating in the Activity. It is my express intent that this Release and Hold Harmless Agreement (hereinafter “Agreement”) shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Agreement shall be construed in accordance with the laws of the State of Florida.


HEALTH CARE AUTHORIZATION: The undersigned hereby authorizes The Arts Corner to perform any acts which may be necessary or proper to provide emergency health care of any student in the event that the parent/guardian and/or emergency contact cannot be reached, including consent to and authorization of medical procedures by qualified, licensed physicians, dentists, hospital or other emergency medical personnel, as they, in the exercise of their profession and in their sole discretion, may deem necessary. The undersigned understands that (s)he is responsible for all costs and expenses of such medical treatment.


PHOTO RELEASE: I give permission to photograph my child for educational purposes such as inclusion in art education student teaching portfolios, presentations at conferences, and to promote the work of The Arts Corner.


In signing this agreement, I acknowledge and represent that I have read and understand it; that I sign it voluntarily and for full and adequate consideration, fully intending to be bound by the same; and that I am at least eighteen (18) years of age, fully competent, and the legal parent or guardian of my Child.



Child’s Printed Name_____________________________________________________________

Parent’s Printed Name ____________________________________________________________


Signature______________________________________________________ Date____________



* The Arts Corner will keep this form on file for future reference. Please notify the staff of any changes to the above information.




PDF copy of photo release and waiver for download

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