Mobile After-school REGISTRATION


What school does your child attend? *
Parent's Name *
Parent's Name
Home Address
Home Address
Phone contact 1
Phone contact 1
Phone contact 2 *
Phone contact 2
Student Information
Student Name
Student Name
Birthdate
Birthdate
Student Information 2
Student Name
Student Name
Birthdate
Birthdate
PAYMENT INFORMATION
Cardholder's First & Last Name *
Cardholder's First & Last Name
Release of Liability
Release of Liability As the legal parent or guardian, I release and hold harmless Jimmy Potters Workshop, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Jimmy Potters Workshop its owners and operators or in route to or from any of said premises.
Photo Release
I grant to Jimmy Potters Workshop, the right to take photographs of my child and his/her work in connection with any Jimmy Potters Workshop class. I authorize Jimmy Potters Workshop, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Jimmy Potters Workshop may use such photographs of my child with or without their name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.