Student Workshop Intake Form

STUDENT WORKSHOP INTAKE FORM

Workshop Information

Workshop Date(s):   Time: From to

Student Information

Date of Birth:   Student ID:

Primary Phone:   Email:

Parent / Guardian Information (if participant is a minor)

Relationship to Student:   Phone:

Emergency Contact

Relationship:   Primary Phone:   Alternate Phone:

Medical Information & Authorization

Medical conditions, allergies, or special needs (describe in full):

Participant has no known allergies or medical conditions:

In the event of a medical emergency, if reasonable attempts to contact the person(s) listed above are unsuccessful, I hereby authorize the workshop staff or representatives to obtain medical care for the participant and to consent to any emergency medical treatment, hospitalization, or procedures as deemed necessary by licensed medical personnel. I understand that reasonable effort will be made to notify the parent/guardian or emergency contact prior to treatment when practicable. I accept responsibility for any costs incurred for such treatment and agree to indemnify and hold the workshop and its staff harmless from any claims arising from authorized emergency care.

Participation Agreement & Liability Release

I acknowledge that participation in the workshop may involve physical activity and potential risks. By signing this form I assume all risks associated with participation, including travel to and from the location, and I release and hold harmless the workshop organizers, instructors, volunteers, and venue owners from liability for injury, loss, or damage to person or property resulting from participation except where such injury or loss results from gross negligence or willful misconduct. This release extends to claims brought by or on behalf of my child or myself.

I agree to abide by the code of conduct established by the workshop. I understand that failure to comply with rules, or behavior that endangers others, may result in removal from the workshop without refund.

Media Release

Photographs, audio recordings, and video may be taken during workshop activities for educational, promotional, and archival purposes. Please indicate your permission preference below.

I consent to the use of my or my child's image and/or voice for non-commercial educational and promotional materials: Yes No

Transportation (if provided)

I authorize transportation arranged by the workshop organizers for travel to and from off-site program activities:

Special transportation instructions or restrictions:

Fees, Refunds & Payment

Workshop Fee: $   Payment Method:

Refunds are subject to the workshop's published cancellation policy. I understand that fees may not be refundable for cancellations within a specified period prior to the event.

Acknowledgment

By signing below I certify that the information provided on this form is true and accurate to the best of my knowledge. I have read, understand, and agree to the Medical Authorization, Participation Agreement, Media Release, and other terms contained herein. I understand that this form will be kept on file for the duration of the workshop and for the period required by applicable recordkeeping policies.

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