Student Enrollment Application Visual Arts: Lascaux Program Family qualifies under:EconomicSocial Category Please attach a copy of your benefits card or proof of enrollment at a continuation middle/high school. Student Parent/Guardian Emergency Contact Medical Care Ethnicity Please check all that apply to the student’s ethnicity: African AmericanAlaska NativeNative AmericanCaucasian/WhiteHispanic/LatinoAsian AmericanPacific IslanderDeclineOther Participation, Release and Consent Visual Arts: Lascaux Program Authorization for Release of YouthYESNO Clarissa Creative Foundation (CCF) requires all students to be picked up by a parent, guardian or other authorized person. This is done for the protection of your child. However, if you want your child to leave on their own, you may request an exception to this policy. Photo Release of YouthYESNO Student Photo Release PermissionYESNO I consent to the unrestricted use by CCF, or any person authorized by them of any photographs, recordings, interviews, or similar visual or auditory recordings of my child. I understand that my child’s image may be edited, copied, exhibited, published or distributed by ARTS, and I waive the right to inspect or approve the finished product. Additionally I waive any right to royalties or other compensation arising or related to the use of my child’s image or recording. I also understand that this material may be electronically displayed via the internet or in a public educational setting. There is no time limit on the validity of this release nor is there any geographic limitation of where these materials may be distributed. Permission to ParticipateYESNO I, the undersigned, consent for my child to participate in the CCF program. I agree to hold harmless CCF against any liability, loss, or expense incurred or suffered in consequence of any action, suit, or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, development, conduct, and execution of the CCF programs. Behavior PolicyYESNO We ask that every student treats each other with respect including Teaching Artists, volunteers, staff, visiting artists, and students. I have read the behavior policy and agree to the terms. CCF has zero tolerance to bullying. Release of Information/RecordsYESNO I, the undersigned, consent CCF to have my child complete a confidential survey about his or her attitudes, learnings and opinions as part of a program evaluation. I understand the information obtained will be statistically analyzed and that my child’s last name will be withheld for confidentiality. I understand that this information, in addition to the survey, will be part of a larger program evaluation, and only the evaluation team and CCF staff will have access to this confidential information. Medical ConsentYESNO I understand that there are some risks inherent in the activities included in the CCF program, but willingly assume these risks in order to allow my child to participate. If I cannot be reached in the event of an emergency, I give permission for any care or treatment by a physician, surgeon, hospital, nurse, and doctor’s assistant or medical care facility that may be required. ArtworkYESNO Student Permission for ArtworkYESNO I fully understand that my child’s artwork may be displayed at CCF, and on their website, marketing materials, promotions, fundraising, and in the community. I understand that CCF will only use my child’s first name. Any student artwork not taken after the show or performance will become property of CCF unless otherwise stated in writing by the student. Signature