Parental Authorization Form printable pdf download

Parental Authorization Form

Child Name: ______________________________________ Birth date __________ Age __________

Guardian Name (1) _________________________________

Guardian Name (2) _________________________________

The undersigned(s) being the lawful parent(s) and/or guardian(s) of the above child (the "Child"),

hereby consents to the participation by the Child in The ARTrepreneur Summer Academy (“Activity”),

which involves creating art projects and following an entrepreneurial curriculum. The camp will be

held at The Lawrence and Isabel Barnett Center for Integrated Arts and Enterprise (131 Sullivant Hall

1813 N. High Street Columbus OH, 43210 ) at The Ohio State University and is conducted by Mosaic

Education Network, LLC (“Organizer"). The undersigned(s) consent to the participation of the Child

in all events relating to The ARTrepreneur Summer Academy. The undersigned hereby further

authorize(s) any of the staff, employees, agents and representatives of Organizer to provide for, approve

and authorize any health care at any hospital, emergency room, doctor’s office or other institution;

employ any physicians, dentists, nurses, or other persons whose services may be needed for such health

care; review and if necessary disclose the contents of any medical records; execute any consent form

required by medical, dental or other health authorities incident to the provision of medical, surgical or

dental care to the child. Health care shall include but not be limited to the administration of anesthesia,

X-ray examination, performance of operations, diagnostic and other procedures.

If there is no medical emergency, the Organizer or affiliates will first use reasonable efforts to contact

the parent(s) and/or guardian(s) before administering or authorizing any treatment. Notwithstanding

other provisions in this Consent Form, Organizer shall not have the authority to withhold or withdraw

life-sustaining procedures for the Child.

The undersigned assume(s) all risk of injury or harm to the Child associated with participation in the

Activity and agree(s) to releases, indemnify, defend and forever discharge the Organizer and its staff,

employees and agents (collectively the "Organizer") of and from all liability, claims, demands,

damages, costs, expenses, actions and causes of action (collectively the "Claims") in respect of death,

injury, loss or damage to the Child or by the Child, howsoever caused, arising or to arise by reason of

or during the Child's participation in the Activity. This Consent Form may be revoked at any time

before the expiration date with written notice to Organizer.

Signature of Parent/Guardian __________________________________________________________

Signed on ________________ (date), at _______________________ (city), _______________ (state).

Parental consent for photographs and video

I hereby grant full permission to mosaic education network and he Lawrence and Isabel Barnett Center

for Integrated Arts and Enterprise to use the above participants photographs and videotapes,

publications, social media outputs, recordings, and other records of events. __Yes __No

Signature of Parent/Guardian __________________________________________ (date)__________

Parent/Guardian Print ______________________________________

Parental Authorization Form