Training for Artist-Educators – Registration Registration Form PARTICIPANT Participant Name Date of Birth Phone number where you can receive text messages Email Address Please tell us why you are interested in doing our Artist-Education training. Art Form EMERGENCY CONTACT Contact Name Relationship to Participant Contact Phone MEDIA RELEASE FORM I, the individual pictured/filmed/videoed, do hereby grant permission to Kick Start Arts Society, their Artistic Directors and assigns to use and reproduce any media, video footage, writing, audio recording, or photographs taken/used/created during the process of participating in the writing/acting classes which are part of the Artist-Educator Training, for use on television, in festivals, and shows, in workshops, or in print, on the internet, or any other format, in any manner suitable to promote and air this project, or others created in the future. Where appropriate, Kick Start Arts Society will acknowledge participants fully for their role. By signing below I/we (the participant or parent/guardian) acknowledge, understand and agree to the Artist-Educator Training Media Release Form. HEALTH ADVISORY We value the health and well being of all participants. If I show signs of being sick, including but not limited to: Runny nose or nasal congestion Headache Extreme fatigue or tiredness Sore throat Muscle aches or joint pain Gastrointestinal symptoms (such as vomiting or diarrhea) Loss of taste or smell I agree that I will advise the instructors, and depending on the issue, I will mask, or will not attend that session. Participant Signature Date Reset Form
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