Artes Culturales Enrollment FormParticipant Name:* First Last Parent/ Guardian Name:* First Last Emergency Contact InformationIn the case of an emergency we will first call the parent/guardian's contact information that we received on the participant application. The emergency contacts below are the second and third people we will call in case we can't get a hold of the first. Emergency Contact 1:* First Last Relationship to Participant:*Phone Number:*Emergency Contact 2: First Last Relationship to Participant:Phone Number:Household IncomeBy sharing your household income, HSTF is able to continue to provide low-cost art group lessons to our community through city and statewide grants. Select your household size (make sure to include yourself):*1 Person2 Persons3 Persons4 Persons5 Persons6 Persons7 Persons8 Persons or more.Select the income range that best describes your household below ( 1 Person):*Column 1: $0 to $29,460Column 2: $29,461 to $49,100Column 3: $49,101 to $78,560None (outside income range)Select the income range that best describes your household below ( 2 Persons):*Column 1: $0 to $33,660Column 2: $33,661 to $56,100Column 3: $56,101 to $89,760None (outside income range)Select the income range that best describes your household below ( 3 Persons):*Column 1: $0 to $37,860Column 2: $37,861 to $63,100Column 3: $63,101 to 100,960None (outside income range)Select the income range that best describes your household below ( 4 Persons):*Column 1: $0 to $42,060Column 2: $42,061 to $70,100Column 3: $70,101 to $112,160None (outside income range)Select the income range that best describes your household below ( 5 Persons):*Column 1: $0 to $45,450Column 2: $45,451 to $75,750Column 3 :$75,751 to $121,200None (outside income range)Select the income range that best describes your household below ( 6 Persons):*Column 1: $0 to $48,810Column 2: $48,811 to $81,350Column 3: $81,351 to $130,160None (outside income range)Select the income range that best describes your household below ( 7 Persons):*Column 1: $0 to $52,170Column 2: $52,171 to $86,950Column 3: $86,951 to $139,120None (outside income range)Select the income range that best describes your household below ( 8 Persons or more):*Column 1: $0 to $55,530Column 2: $55,530 to $92,550Column 3: $92,551 to $148,080None (outside income range)Medical InformationThis section of the form will ask you to complete information about the participant's medical conditions or other important medical information.Does the participant have health insurance?* Yes No If you selected "yes," please provide the participant's health insurance provider:*If you selected "yes," please provide the name of the policyholder:*If you selected "yes," please provide the policy number:*Select any of the following medical conditions the participant has:* None Asthma Diabetes Seizures ADHD Anxiety/ Depression Mental Health Diagnosis Other If you selected "Other or Mental Health Diagnosis" to the question above, provide details below:*Use this space to inform us of any learning, emotional, and/or behavioral supports the participant may need within our program:Does the participant have any allergies?* Yes No If you selected "yes" to the question above, list them below:*Does the participant use any of the following?* Inhaler Epipen Insulin Self-Administered Medication Other None If you selected "Self-Administered Medication or Other", list below:*Are you concerned about a medical condition that will potentially prohibit the participant's participation at HSTF?* Yes No If you selected "yes," explain below:*ConsentsHere are HSTF's Medical, Photo/ Video, and Liability forms. Select an option below for each. The signature and date at the end will sign all three forms. Medical Consent*I hereby give Hyde Square Task Force permission to administer basic First/Aid and/or CPR and/or take my child to a hospital and secure medical treatment when I cannot be reached or when delay would be dangerous to my child's health. You have my consent. You DO NOT have my consent. Release and Waiver of Liability Agreement for Participation (Participant and Parent/Guardian)* I hereby agree to the following:This agreement is by and between Hyde Square Task Force (herein referred to as HSTF) and the individual whose name is signed and printed below (herein referred to as participant). 1. I am participating in the Artes Culturales at HSTF, during which I may participate in physical activity workshops. I recognize that participation in such activities requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. 2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Artes Culturales Program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the Artes Culturales Program. 3. In consideration of being permitted to participate in the Artes Culturales Program, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participating in the program. 4. In further consideration of being permitted to participate in the Artes Culturales Program, I knowingly, voluntarily and expressly waive any claim I may have against HSTF and its employees, board members, officers, volunteers, and staff for damages, and injury, including death, that I may sustain as a result of participating in the Artes Culturales Program. 5. I and my heirs or legal representatives forever release, waive, discharge and covenant not to sue HSTF and its employees, board members, officers, volunteers, and staff for any injury or death caused by my voluntary participation in the Artes Culturales Program. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. This agreement remains in effect for as long as I participate in the Artes Culturales Program.Participant Signature:*Parent/Guardian Signature:*Date* MM slash DD slash YYYY Δ
