Loading...

Parental Permission to treat, film and/or photograph


FLYING GRAVITY CIRCUS programs include but are not limited to: Performance Troupes, Pre-Troupe, Open Training, Summer Tour, Silver Lining Circus Camp, Adult Classes, Private Lessons, Circus After School Programs, Circus Workshops and Circus Residencies.

THIS FORM MUST BE COMPLETED IN FULL AND RETURNED TO FLYING GRAVITY CIRCUS PRIOR TO THE FIRST DAY OF PROGRAM.

 

In the event I cannot be reached in an emergency, I hereby give permission to the FLYING GRAVITY CIRCUS STAFF to secure proper treatment for the person named below. I expect to be notified immediately.

I Agree

I hereby authorize FLYING GRAVITY CIRCUS staff to administer and medication(s) I have indicated in the health form to my child/teen as indicated. I understand that there is no physician on site at FLYING GRAVITY CIRCUS programs.

I Agree







First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Media Release
I give FLYING GRAVITY CIRCUS permission to take and reproduce photographs, video, and/or other recordings of my child/teen while he/she is participating in any FLYING GRAVITY CIRCUS program. I give FLYING GRAVITY CIRCUS permission to include my child/teen's name, age and town of residence along with photographs and/or video and/or other recordings, and to provide this information to the media. I agree that FLYING GRAVITY CIRCUS shall have exclusive rights to use, and to authorize others to use the material resulting from said photographs and/or video and/or other recordings in any way FLYING GRAVITY CIRCUS wishes, including but not limited to using it on publicity materials including the FLYING GRAVITY CIRCUS website, CIRCUS AFTER SCHOOL PROGRAM website, SILVER LINING CIRCUS CAMP website, Circus in a Box website, advertising, films, interview, documentaries, books, television productions, and brochures, in print and/or electronic media including Facebook, Instagram, and sometimes in presentations by our staff for educational purposes.*
Yes
No
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!