Student Medical Release Form.

This form must be entirely complete before the student is allowed to attend class.

Name: SEX: ❏M ❏F
First MI Last
Address: City: Zip:

Phone: Age: Birth date: / /

School: Grade:

Parent’s Name: Phone:

Email Address:____________________________________________________

Alternate Contact:____________________________________Phone:______________

Please read and initial the following:

• I give consent and authorize Chrissy Colbert to use my child’s photograph and/or
artwork for education and public relations purposes on her website/blog. ❏Yes ❏No Initials
_______

List any allergies to food, insects, medication, etc. Describe allergic reactions and their severity.

Are there any special needs or concerns of your child that I should be aware of?

Please read carefully the following and initial.

Should any injury occur during or as a result of participation in any Squiggles Children’s Art
Class, workshop, camp or program I agree to indemnify and hold harmless Chrissy and all her
employees, instructors, and volunteers connected with Squiggles Children’s Art Classes.
Initials ________

Signature:____________________________________________________ Date:__________________