Select Camp to Register to *
STUDENT INFORMATION
Student Name *
Student Name
PARENT/GUARDIAN CONTACT INFORMATION
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Home Phone Number *
Parent/Guardian Home Phone Number
Parent/Guardian Cell Phone Number
Parent/Guardian Cell Phone Number
Parent/Guardian Address *
Parent/Guardian Address
SECONDARY CONTACT INFORMATION
Secondary Contact Name *
Secondary Contact Name
Secondary Contact Home Phone Number *
Secondary Contact Home Phone Number
Secondary Contact Cell Phone Number
Secondary Contact Cell Phone Number
WAIVERS
INFORMED CONSENT AND WAIVER/RELEASE (REQUIRED) *
INFORMED CONSENT AND WAIVER/RELEASE (REQUIRED)
On this day, intending to be legally bound hereby, the undersigned agrees and does hereby release from liability and to indemnify and hold harmless AIA Arizona, AIA Phoenix Metro, and any of its employees or agents and mentors representing or related to the Arizona Kids Build learning field trip and workshops. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for this workshop.
Date Signed *
Date Signed
PERMISSION FOR TREATMENT IN MEDICAL EMERGENCY (REQUIRED) *
PERMISSION FOR TREATMENT IN MEDICAL EMERGENCY (REQUIRED)
I understand that my signature below is both a medical and liability release. If any accident should occur, I hereby authorize Arizona Kids Build (AZKB) to arrange for emergency medical care deemed necessary by Arizona Kids Build. I agree and verify that I will be responsible for any medical costs incurred as a result of the Student’s participation in the Class.
Date Signed *
Date Signed
MINOR MODEL RELEASE (NOT REQUIRED)
MINOR MODEL RELEASE (NOT REQUIRED)
Arizona Kids Build (AZKB) has my full permission to use my child(ren)’s photographs, or likeness for any promotional purposes that Arizona Kids Build deems appropriate. These purposes may be for internal or external use and may include collateral material for marketing of the program and grant submittals. No names of children will be used in conjunction with these photographs. I have read and understood, and I agree with the informed consent and waiver/release, and minor model release outlined above as it relates to my son(s)/daughter(s).
Date Signed
Date Signed
PLEASE VERIFY ALL INFORMATION ON THE FORM IS CORRECT BEFORE SUBMITTING.
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