2019-20 LAcademy Holidays/Spring Break Camps Online Registration Form

Student First Name: *

Student Last Name: *

Street Address: *

City: *

Zip: *

Age: *

Male / Female *

Birthday: *

Email Address: *

Home Phone: *

Work Phone: *

Cell Phone: *

Grade: *

Current School & Teacher Name: *

Parent / Guardian Names: *

Emergency Contact: *

Emergency Contact Phone: *

Which camp are you attending? (We are closed for Thanksgiving, Black Friday, Christmas Day, New Year's Day) *

How did you hear about us? *

Allergies or Special Needs: *

Please list any other special notes here:

RELEASE AND WAIVER OF LIABILITY AND INDEMNITY

By submitting this form you are agreeing and giving consent to the following waiver: Lakeland Academy of Arts Consent, Waiver and Release of Liability, Photo and Video Release On behalf of my minor child (student named on this application), I hereby give permission for my child to participate in the Lakeland Academy (After School Dance Program). I hereby warrant that both myself and my child are familiar with the risks associated with participation in Lakeland Academy activities. I acknowledge that my child’s participation in this program is wholly voluntary and is not part of the regular school curricular program. I do hereby agree and consent to my child’s participation in Lakeland Academy during this school year and do assume all risks and hazards which are conducted as part of the associated activities. I hereby release, absolve, indemnify, and hold blameless Lakeland Academy , directors, employees, contracted employees, independent contractors, instructors, agents, organizers, and volunteers of any and all liability for damage, injury, or expense of any kind arising out of or connected with my child’s participation in Lakeland Academy programs. I understand that in the case of a medical emergency, my own personal medical plan will be used. As a condition of participation in the Lakeland Academy program by the student named in this application, I acknowledge that I have read this consent form, and knowingly, on behalf of my child, assume all of the risks associated with participating in any way in the Lakeland Academy program. As consideration for being permitted to participate in any Lakeland Academy program, I hereby agree that I, my assignees, heirs, distributees, guardians, and legal representatives will not make claim against, sue or attach the property of Lakeland Academy, or their Affiliates or the supplier of any of the equipment used in these activities for injury or damage resulting from negligence, failure of care, omission or other acts, howsoever caused by an employee, agent or contractor of Lakeland Academy and any affiliate as result of incidental to my child participation in these activities. I hereby release, to the fullest extent permitted by law, Lakeland Academy and all affiliates, from any and all actions, claims, demands, or liabilities that I, my assignees, heirs, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my son/daughter’s participation in these activities irrespective of whether the same is based on breach of warranty, negligence, strict liability or any other theory or recovery. I/We understand that as part of our child’s participation in Lakeland Academy, photos, videos, electronic images, audio recordings and quotations of my daughter/son may be taken for use in publications and reports about the program. I/We grant permission for Lakeland Academy to use such materials for the program. Trip permission This form, when returned signed, indicates parental awareness and grants permissions for the student to be picked up via our complimentary after school service, or arrive by other means. I also acknowledge that Lakeland Academy After School Program is an after school dance program and students are not required to sign in and out. *

Online Signature *

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