African American Arts Association Child/Youth Registration Form

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* 1. List Child’s Name and Age & Birthday (All That Apply)
Example: 1. John Doe - 12Yrs - 01/01/2012 2. Jane Doe - 10 Yrs - 02/01/2014

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* 2. Parent or Guardian Name Address/Phone Number/Email Address Example: Jane Doe - 123 Price Rd, Lexington,Ky 40508 - 859-859-8598 - Janedoe@gmail.com

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* 3. Allergies (Child’s Name and allergy) Example: 1. John Doe - Hay Fever 2. Jane Doe - Shell Fish)

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* 4. Medical Issues (Childs name and Medical Issues) Example: 1. John Doe - Asthma 2. Jane Doe - Anaphylaxis

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* 5. Child Photo Video Participation Consent
(Parent/Guardian name and date goes here giving African American Arts Association, Inc., permission to release photos and videos of program participation.) Example: Jane Doe 01/01/2024.

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* 6. Program Selections (Enter Child’s Name and Program Interest) Example: 1. Jane Doe - Critical Condution, Creative Arts, Alpha Girls 2. John Doe - Skills and Drills, Hop-Hop Experience, Planting Generational Seed

List Of Programs: Alpha Girls • Alpha Boys • Critical Condition Dance

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* 7. Child Medical Accident and Incident Waiver
(Parent/Guardian name and date goes here releasing African American Arts Association, Inc., of all accident or incident responsibilities. Childs Parent or Guardian’s insurance on the child is to be used in these cases.) Example: Jane Doe 01/01/2024.

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* 8. Child’s Emergency Contact Name and Phone Number Example: Jane Doe - 859-859-8598

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* 9. Parent/Guardian Signature and Date (Enter your name here consenting to everything being accuracy and correct and giving your consent of programming with African American Arts Association, Inc.) Example: Jane Doe - 01/01/2024