Digital Waiver - Lillian Gray Art School

Parent

Name*Surname*
Cell*Tel Work
Tel HomeEmail*
Home Address*

Details Of First Minor

Name*Surname*
Date Of Birth*
Cell
Home Address
Same as above

Details of Second Minor

NameSurname
Date Of Birth
Cell
Home Address
Same as above

Emergency Contact

Name*Surname*
Cell*

Relationship to Minor*

Pick Up / Collection

Please provide details below of any person/s not permitted to contact or collect your child/ren while in the care of Lillian Gray Art School.

Details of aupair/ granny or any other person allowed to collect your child:

NameSurname
Cell
Relationship to Minor

Confidential Medical Report

The information below is requested to assist in case of any illness or accident, and will be held in confidence.

Please tick below if your child/ren suffers from any of the following:

ADD / ADHD
Temporal Lobe Dysfunction
Asthma
Epilepsy
Travel Sickness
Other

Please tick below if your child is allergic to any of the following:

Penicillin
Bee Stings
Other

Medical/Hospital FundContribution No
Principal Member

IN CASE OF EMERGENCY WE WILL CONTACT YOU DIRECTLY. IF NEED BE, WE WILL TAKE YOUR CHILD TO THE NEAREST HOSPITAL WHICH IS FLORA LIFE HOSPITAL.

I consent to my child participating in events run by The Lillian Gray Fine Arts School. I will encourage my child to attend and participate regularly and to cooperate with the leaders and other children. I authorize the leader in charge of the above-mentioned group to arrange for my child to receive such First Aid. Medical treatment as the leader may deem necessary at any time during the activities of The Lillian Gray Fine Arts School. I accept responsibility for payment of all expenses associated with such treatment.

I agree to indemnify and hold harmless The Lillian Gray Fine Arts School against all claims, demands, suits and liability of whatever nature and howsoever arising out of the injury to the child, and the relevant activity being undertaken.

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.

I Agree

Electronic Signature*

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