UTSA Registration Form

Phone: 210-200-8213/8201
Email:communityart@utsa.edu

YOUTH ART STUDIOS RELEASE FORM

Please note: The Release Form must be filled out by the first day of class or we cannot accept the student in class. Only one release form per student is required, even if the student is enrolled in multiple classes.

STUDENT INFORMATION (PLEASE PRINT CLEARLY)

First Name *

Last Name *

Age *

DOB * +

Street Address *

City *

State *

Zip *

Gender *

City Council District *

School/School District *

Parent/Guardian *

Daytime Phone *

Emergency Contact? *

Yes

No

Parent/Guardian

Daytime Phone

Emergency Contact?

Yes

No

Additional Emergency Contact

Relationship

Daytime Phone

Parent/Guardian Military Affiliation *

	Active Duty Military	Reserve or National Guard	Retired Military	Veteran	N/A
.	Active Duty Military	Reserve or National Guard	Retired Military	Veteran	N/A

I have read and agree to uphold the guidelines for Youth Art Studios. *

Yes

No

PHOTO PERMISSION AND RELEASE
UTSA captures images of Youth Art Studios for its archive and for use in publicity materials

I give permission to UTSA staff and representatives to photograph myself or my child for such purposes: *

	Yes	No
.	Yes	No

DEMOGRAPHIC INFORMATION The following information is used for grants and funding which supports Youth Art Studios

Is the child Hispanic or Latino? *

Yes

No

No matter what you selected above, please mark the appropriate selections below to indicate what you consider the child’s race to be: *

HEALTH INFORMATION

Physician Name *

Daytime Phone *

Dentist Name

Daytime Phone

In order to ensure the highest quality instruction for your student(s) and their classmates, we ask to be informed of any health issues your student may have. UTSA does not and will not discriminate against any student based on gender, race, national origin, ethnic origin, sex, age, religion, disability or any other status protected under federal, state or local laws

Does your student receive special services or accommodations in school? *

Yes

No

Does your student have any current health problems? *

Yes

No

Please use the area below to include any additional information you think we need to know about your student (learning challenges, special accomodations, allergies, etc):

Health problems *

I understand that if my child requires medical treatment while participating in Youth Art Studios, an attempt will be made to notify me. If I cannot be reached, I consent to such treatment for the child as may be deemed necessary under the circumstances, including but not limited to: X-ray examinations, surgery, and anesthesia. I understand that I am responsible for all costs and expenses for such medical treatment. *

Yes

No

TEENS(16 & above) | Parents, note below if your teen has permission to sign themselves out at the end of class (16 & above ONLY) or if your teen is to remain on campus to be signed out by a parent or guardian

My teen has permission to sign themselves out at the end of class. By releasing my teen, I understand they may leave the UTSA Southwest campus and will release UTSA of liability for my student *

Yes

No

N/A

GUARDIAN PICK-UP I grant permission for my child to be picked up by the persons listed below

Name

Daytime Phone

Name

Daytime Phone

Name

Daytime Phone

I hereby release and hold harmless UTSA any officer, agent, contractor, or volunteer from any and all injuries incurred by my child in connection with my child’s departure from the campus with a guardian. *

Agree

SUBMISSION

I release, acquit, and discharge, and agree to indemnify and hold harmless, UTSA, its officers, directors, agents, employees, and contracted employees, against any claim, loss, liability, injury, damage, and expense loss or to property, which participants may, directly or indirectly, sustain or suffer as a result of my child’s participation in classes and use of UTSA Southwest grounds, equipment or gross negligence of UTSA. *

Agree

We have read and agree to uphold these guidelines for Youth Art Studios *

Agree

Signature (Parent/Guardian) *

clear

Parent/Guardian name *

Date *

Thank you! You've completed the registration for this course.

We look forward to having your student(s) on our campus!