Young Artist Club (Registration & Payment)

Student Information

Student's Name *

First

Last

Birthday *

Grade *

Gender *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Primary Phone # *

Alternative Phone #

Email *

Emergency Contact Information

Emergency Contact Name *

First

Last

Relationship to Child *

Primary Phone # *

Alternative Phone #

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Informed Consent & Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by The Spinning Jenny during the selected camp. In exchange for the acceptance of said child’s candidacy by The Spinning Jenny, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless The Spinning Jenny. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against The Spinning Jenny. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including dance. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
I am aware of the existence of the risk on my child's physical appearance to the venue and my child's participation to the activity of the Organization that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.
My child has not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.
My child, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days.
My child has not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days.

Following the pronouncements above I hereby declare the following:

With full knowledge of the risks involved, I hereby release, waive, discharge the Organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me or my child related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.
I agree to indemnify, defend, and hold harmless the Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

Medical Release & Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Spinning Jenny and its affiliates including Teachers, and Team members to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Signature

BY ACKNOWLEDGING AND SIGNING ABOVE, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Payment

Checkbox Items

Monday(grades 1st-5th): Art 10am-11am
Tuesday (grade 1st-5th) : Theatre/Dance 2pm-3pm
Tuesday(grades 6th-12th): Theatre/Dance 4pm-5:30pm
Wednesday(grades 6th-12th): Art 10am-11am
Thursday(grades 1st-5th): Theatre/Dance 2pm-3pm
Thursday (grades 6th-12th): Theatre/Dance 4pm-5:30pm

Total

$ 0.00

Stripe Credit Card *

Card

Name on Card