MakerSpace Release Form

Youth Participant Name *

Age *

Parent/Guardian Name *

Email *

Phone *

Additional Emergency contact name *

Emergency Contact Phone *

Any allergies, medical, or behavioral information HCOA and program teachers/event leaders should know about?

Medical Release *

I consent to allow the above-named participant to receive emergency treatment, hospitalization, or other medical treatment by a physician, qualified nurse, or hospital if necessary because of an injury or illness.

I hereby waive any liability for injuries/illness sustained at this program/event produced by Homer Council on the Arts. I also accept legal and financial responsibility for the above-named participant in the event of injury or illness.

Media Release *

Yes. Homer Council on the Arts may use a photo/s or video/s of me for promotional purposes. I understand that my name and other personal information will not be released.

No. Homer Council on the Arts may not use a photo/s or video/s of my student for promotional purposes.

Signature *

The information I have provided on this form is accurate.

I have read and understand all the release statements, and agree to all terms.

Signature

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MakerSpace Release Form

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