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Youth Emergency Contact Sheet

The following information is confidential and will not be shared outside of studio use.

NOTE: We may contact you ahead of programing start date to discuss any health related matters. This will be to ensure we stay well informed and can support your child under your best direction while they in our care. We look forward to your child having an exceptional time learning and creating with us.


Date signed: February 25, 2024

First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
First Participant's Signature*
Second Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Third Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Fourth Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Fifth Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Sixth Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Seventh Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Eighth Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Ninth Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Tenth Participant's Name

First Name*

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

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contacts: please fill out at least one emergency contact

1. Name:

Relation:

Contact Number:

2. Name

Relation:

Contact Number:
***Photography Consent***
By way of this signature, I the releaser consent to any photographs taken of students including myself or my child while in this studio location to be used for promotional, social media and other marketing materials produced by the Under the Sun Stained Glass and Glass ArtStudio.*
No
Yes
Consent to Leave; please list the person who will be picking up your child on the day(s) of event

Name:

Relation:

Contact Number:
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*

Last Name*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Under The Sun Program Registration Course Name:

Program Course Registration Date(s):

Student Preferred Name (if different from name listed above):

Health Care Plan Number:

While your child is in our care please advise us on if any of the following are applicable: 


1. Health Concerns (ie. Diabetic, Epilleptic, requires Epi Pen for___, ect...)

2. Visual/Hearing Aids

3. Mobility Aids

4. Allergies
5. While in our care, will your child require any medications?*
No
Yes

If Yes, please provide instructions

6. Other Special Considerations we should be aware of
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.


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