Emergency Contact – Living Arts and Science Center

Thank you for registering for a class at the Living Arts & Science Center

We want our students to have a happy and enriching experience at the LASC.

This information is confidential and will only be shared with staff members involved directly with the student.

Please submit this form prior to the first day of class.

*denotes a required field

Student's Name*

Birth Date*

Grade*
(In summer, please enter Last Grade Completed)

School

Parent/Guardian 1 (If student is under 18)

Name*

Relationship*

Email*

Home Phone*

Cell Phone*

Work Phone

Place of Employment

Parent/Guardian 2 (If student is under 18)

Name*

Relationship*

Email*

Home Phone*

Cell Phone*

Work Phone

Place of Employment

Emergency Contact Name (Someone NOT listed above)

Name*

Relationship*

Phone*

Who has permission to pick up this student?* (Include first and last names of all transportation, including parents/guardians listed above. We require a signed note for anyone else to pick up a student under 18.)

Check here to give permission for your child to sign themselves in and out or class*
(Only applicable to students age 13 and over.)
YesNo

1. List student allergies as well as all pertinent medical, physical, emotional, or social concerns.* (If the student has an IEP or behavior plan at school, please consider attaching a copy for our staff to review.)

2. Do you have any other concerns or suggestions for those working with you or your child?*

Media Release: I give permission for the Living Arts & Science Center or those designated by the LASC to collect and use the likeness, photograph, voice, written word, artwork or direct quotes of the above named student. Such documentation may be used on the LASC website, in promotional materials, media broadcasts and publications, or other such materials. Select photos will be shared with the Association of Science and Technology Centers. This release also provides them with permission to use the photos in their publications and materials. I release the Living Arts & Science Center from any liability or responsibility for this use.*
YesNo

By submitting this form, I certify that all information provided on this form is accurate and that I have read, understand, and agree to adhere to the LASC class guidelines.
I accept