Participant Intake & Waiver Form

CHILD’S INFORMATION

PARENT/GUARDIAN INFORMATION

GETTING TO KNOW YOUR CHILD

No experience is necessary for this workshop — just courage, creativity, and a willingness to learn and explore! To help us support your child’s growth and experience, please let us know:

LIABILITY WAIVER & MEDICAL CONSENT

I, the undersigned parent or legal guardian of the child named above, acknowledge and agree to the following:

I understand that the Rhythm & Roots workshop involves physical activity, including movement, dance, and games, which carry some inherent risk of injury.

I release the Bonifacio Valera, Jr. Foundation, its officers, instructors, volunteers, and venue (Moving Arts Academy) from any and all liability, claims, or demands for injuries, losses, or damages incurred by my child during participation in this program.

In the event of a medical emergency, I authorize the staff to seek appropriate medical care for my child, and I accept responsibility for any related expenses.

MEDICAL & EMERGENCY INFORMATION

Please list any relevant medical conditions, allergies, or accessibility needs your child has. This helps us ensure a safe and supportive environment.

PHOTO / MEDIA RELEASE

The Bonifacio Valera, Jr. Foundation may photograph or record program

activities for promotional, educational, or archival purposes. These images may be used in print, on our website, or on social media.

AUTHORIZED PICKUP / DROP-OFF

For your child’s safety, only authorized adults will be allowed to pick them up from the workshop.

Please list all individuals (including yourself) who are authorized to pick up your child:

ADDITIONAL INFORMATION

PARENT/GUARDIAN ACKNOWLEDGMENT & ELECTRONIC SIGNATURE

By signing below, I confirm that the information provided in this form is accurate and complete to the best of my knowledge.

I have read and agree to the terms outlined in this form, including the Liability Waiver, Medical Consent, and Photo/Media Release (as selected above).