Child Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone Number #1 *

(###)

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Parent/Guardian Phone Number #2

(###)

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone #1 *

(###)

###

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Emergency Contact Phone #2

(###)

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Participant Consent *

By checking YES, I give permission for my child to participate in any class activities.

YES

Photo Release *

By checking YES, I give permission for any photos or videos taken of my child during the Young Chefs program to be released to the media and granting organizations for program publicity purposes.

YES

NO

Emergency Medical Consent *

By checking YES, in the event of any emergency, I authorize Rockport Center for the Arts to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered. I understand that this authorization includes transporting my child by ambulance if necessary to the nearest medical treatment facility if I am unable to be reached first.

YES

NO

Liability Release *

By checking YES, I understand that ROCKPORT CENTER FOR THE ARTS makes every effort to provide a safe environment for my child, and I release ROCKPORT CENTER FOR THE ARTS staff, Board members, volunteers and any representatives associated with the Young Chefs program, from any potential liability for any and all claims of injury, illness, and/or accident which may directly or indirectly result from my child’s participation in the program(s).

YES

Transportation Confirmation *

By checking YES, I understand that I must provide transportation to The Rockport Conference Center (106 S Austin St. Rockport, TX) and pick up my child at the completion of every session. Children must be picked up no later than 15 minutes after the completion of the session. Please contact Kathleen@rockportartcenter.com to add authorized individuals for pick up.

YES