PERMISSION SLIP

November 12 and Nov 19^th  Dec 3^rd Exhibition 1:00-2:30

Saturday Morning Art Classes SMAC 2011 9:30-11:30 & 12:30-2:30

ODU CAMPUS http://www.odu.edu/oduhome/campusmap.shtml

Classes held at both university locations:

Art Studio Building (in Village) at Monarch Way and 46^th Street – Parking garage “D” or lot at Ceramics Studio #108

and

Visual Art Building (Across from Football Stadium at 49^th) Old Dominion University Art Department. Visual Arts Building, 49th Street, Norfolk VA 23529. 757 683 4047

PERMISSION SLIP/PARTICIPANT AGREEMENT, INDEMNIFICATION, AND ACKNOWLEDGEMENT OF RISKS FOR MINORS

I acknowledge my child’s participation in the ODU Art Education Program Children’s Art Classes taught by university students enrolled in Art 406; activities include known and unanticipated risks. 

In consideration of MY CHILD being permitted to participate in activities, use equipment and facilities and visit/walk through the university urban campus for classes.

Please complete permission form and bring this to the registration tables on the first day of class… print clearly; student information:

Print Student’s Name:______________________________________________________

Print Address: _____________________________________________________

Print Grade and Date of Birth:__________________________________________________
Parental Information:
Name of Parent or Guardian:________________________________________

Home/Cell Phone:_____________________Emergency  Cell Phone:____________________

Relationship to Student:___________________________________________

E-mail address (please print clearly): _______________________________________________

IN CASE OF EMERGENCY:

I/We make every effort to provide a safe and secure environment for your child during teaching/class/workshop events. In order to better to protect the safety and health of your child, I/we request that you provide the following information:  In case of an emergency, I/We will contact the parent listed above. I/We request that the parent provide another contact (not living at the same address) who is authorized by the parent to act on his/her behalf should the parent not be available.
Additional Emergency contact: Name:___________________________________________________
Address:__________________________________________________
Phone Number:____________________________________________
Relationship to Parent/Student:_________________________________
PLEASE INDICATE list any health conditions, allergies or diet/mental/physical restrictions that your child may have and medications that he/she may be using to treat this condition. Indicate if the child has your permission to take such medication while attending the event. You may also include the name of the hospital or doctor of your choice and their phone numbers:
________________________________________________________________________________________________________________________________________________________________________________________

I authorize personnel to call for medical care for the minor and/or to transport the minor to a medical facility or hospital if, in the opinion of such personnel, the minor needs medical attention.  I further authorize appropriate personnel to render such medical treatment as is necessary for the health of the minor, in their professional opinion.  I agree that once the minor is in the care of medical personnel or a medical facility, the organization shall have no further responsibly for the minor and I agree to pay all costs associated with such medical care and transportation.

I authorize that my child may visit, transport/walk to buildings on the campus and participate in the urban university setting both at the Studio Art Building and Visual Art Building.

Date of his/her last tetanus shot ________.

He/She is allergic to _________________________ and I have noted his/her physical limitations on the back of this form. During the activity, I may be reached at: Address _______________________________ Phone _______________ If  I cannot be reached in the event of an emergency, the following person is authorized to act in my behalf:

Additional Remarks _______________________________________________________
By signing this form, I declare that I am the legal parent/guardian of the minor child listed above and authorized to grant such permission.

Model Release:

Authorization for photography of minor and to reproduce photographs and use images in press, publication and web-site and various blog formats.  I hereby grant permission to the rights to photography for my children to use in connection with the promotion of the Art Education Program, research and its departments including news releases, feature articles, print media, newsletter and publications, web sites or formats as needed.  I understand that there is no remuneration/compensation for this use or reproduction of said photographs. 

Other person other than yourself provide transportation to and from this event, please indicate the name and phone number of such person:

Transportation pick up .drop off: ______________

Permission Notice:
My son /daughter______________________________________________________________ has permission to participate in Children’s Art Classes.

_____________________________________________                  ___________
 (Parent's Signature)                                                                            Date