Carrie Heller, M.S.W., L.C.S.W

Carrie Heller, M.S.W., L.C.S.W.

206 Rogers St. N.E. suite 214

Atlanta, GA.30317

404-549-3000

CAMPER, FAMILY AND HEALTH INFORMATION FORM

Your assistance in supplying the following information is appreciated and will be used in strict confidence.

Date:______Your e-mail address ______

Client name:______Age:______

Date of birth:______Sex:____ Race:____

School client attends: ______

Grade: ____County:______Teacher’s name:______

Father’s name:______Home phone:______

Father’s employer:______

Father’s business phone:______Father’s cell phone:______

Mother’s name:______Home phone:______

Mother’s employer:______

Mother’s business phone:______Mother’s cell phone______

Home address (please include zip)______

______

Marital status of parents:______If applicable,

Dates of separation______and date of divorce______

Name of family doctor/pediatrician:______

The following people are authorized to pick up my child from the Circus Arts Institute facility:

______

Carrie Heller, M.S.W., L.C.S.W.

Carrie Heller, M.S.W., L.C.S.W.

206 Rogers St. N.E. suite 214

Atlanta, GA.30317

404-549-3000

CIRCUS ARTS SOCIAL SUMMER INFORMATION FORM

Please fill out the following information to assist us in planning for your child's success in the CASS program:

Please list any chronic illness/recurring medical condition, dietary restrictions or

food allergies you would want us to be aware of ______

______

Has your child been given a formal diagnosis? if yes, what is it? ______

______

What do you hope your child will take away from his/her experience at CASS?

______

What do you find helps your child to calm down when s/he is upset? (hugs from us, hearing our voice talking calmly to them?)

What are the specific social behaviors you would like your child to work on during this session?

______

Do we have your permission to share your name and child's name with other interested parents? ______

Signature of Parent or legal guardian: ______

Date: ______

Carrie Heller, M.S.W., L.C.S.W.

206 Rogers St. N.E. suite 214

Atlanta, GA.30317

404-549-3000

Conditions of Enrollment & Enrollment Agreement

I have filled out the enclosed forms and they are correct so far as I know, and the participant herein described has permission to engage in all prescribed activities except as noted.

The participant, his/her parents or guardians agree to abide by the rules set by CASS as follows for the health, safety and welfare of the program. CASS reserves the right to dismiss a participant whose conduct or influence is detrimental to the group. If this becomes necessary, there will be no tuition refund. The Director will consult with the parents before dismissing a participant.

CASS is not responsible for articles of clothing or personal belongings lost or damaged. Please label all items. Do not bring valuables to the CASS facility.

Participants are expected to remain on premises unless the CASS office is notified in writing.

In the event that a parent cannot be notified, I hereby give permission to the doctor selected by CASS to hospitalize and secure proper treatment for the participant listed. I agree to reimburse CASS for any and all costs it may incur for the medical treatment of the participant.

It is expressly understood by the parent/guardian of the participant for whom this reservation is requested that the participant is in a condition of health and soundness of body that warrant him/her undertaking the program as outlined in the CASS literature.

I understand that all participants are supervised by staff trained in the arts of the circus. In the event of accidental injury, I agree not to hold Carrie Heller, MSW, LCSW, CASS individual staff members or Sensations Therafun™ liable and to pursue any claims on my own insurance policy.

I acknowledge it is my responsibility to keep my child's record current to reflect any significant changes as they occur, i.e. phone numbers, emergency contacts, child's health status and who is authorized to pick up the child.

I am aware thatmy balance is due before June 14th. We do encourage you to return your balance with this form.

PLEASE MAKE ALL CHECKS PAYABLE TO:

Circus Arts Institute, LLC mail this form and payment to :

Circus Arts Institute
206 Rogers Street N.E., Suite 214
AtlantaGA30317

PHONE: 404-549-3000

THERE WILL BE NO REFUNDS AFTER May 17th

I hereby enroll my child(ren) in CASS. I have read and understand this Enrollment Agreement and all forms attached. I agree to abide by the written policies and procedures of CASS. We agree to keep you informed of any incidents, such as illness or injury which involve your child.

______

Signature of ParentParent Name (Please Print)Date

For:

______Participant(s) Name(s) (Please Print)

Release of Liability

PLEASE READ CAREFULLY

Circus Arts Institute operates with a high level of safety consciousness, and all our teachers and staff are trained and proficient in the arts of the circus. However the exercises and activities performed in circus training are more dangerous than normal activity.

Please share any pre-existing medical conditions that you may have.

ASSUMPTION OF RISK

I, the undersigned Participant, or if under the age of eighteen, the Parent or Legal Guardian of the Participant(s), do hereby acknowledge that there is the possibility of accidental or other physical injury when participating in one or more of the Circus Arts Fitness sessions, Circus Arts Therapy sessions, Circus Arts Social Summer, private sessions, Corporate Teambuilding and any and all activities or programs of the Circus Arts Institute. I understand and assume the risk of such injury to myself or to my child(ren). I represent that I or my child(ren) am/is/are/ in an able physical condition to participate in the circus exercises and activities and that I have health insurance in force which provides coverage in the event of any injury I or my child(ren) might sustain. I agree to pursue any claims on my own insurance policy. I further certify that I am willing to assume the risk of any medical or physical condition that I or my child(ren) may have.

In signing this document, I hereby accept and assume total and complete responsibility and liability for any such injury and all expenses related thereto. I hereby agree to hold harmless Carrie Heller, Circus Arts Institute, LLC, Henry Finkbeiner, The Warehouse Limited Partnership, Inc. and any and all instructors, independent contractors, or volunteers in the Circus Arts Fitness sessions, Circus Arts Therapy sessions, Circus Arts Social Summer, private sessions, Corporate Teambuilding and any and all activities or programs of the Circus Arts Institute related for any injury to myself or to my child(ren) and for any loss or damage to personal property. I hereby agree to indemnify Carrie Heller, Circus Arts Institute. LLC,Henry Finkbeiner, The Warehouse Limited Partnership, Inc., and any and all instructors, independent contractors and volunteers in the Circus Arts Fitness sessions, Circus Arts Therapy sessions, Circus Arts Social Summer, private sessions, Corporate Teambuilding and any and all activities or programs of the Circus Arts Institute related for any costs, losses or damages incurred from any claims, actions or lawsuits (including without limitation, reasonable attorneys fees and disbursements) by third parties which arise from or are a direct consequence of my or my child(ren)'s actions or failures to act.

In consideration of myself I and/or my child(ren) being permitted to participate in circus activities, I and/or my child(ren) hereby agree that I/we have read and understand this document and I/we agree to be bound by the terms of this document. I acknowledge that this release is continuing in nature and shall bind me for subsequent activities, sessions or programs of the Circus Arts Institute that I may engage in from time to time. Circus Arts Institute retains the right to require execution of a new release in its discretion and from time to time.

PARTICIPANT(S) NAME(S) Please print ______

DATE SIGNED: ______

Participant Signature or PARENT/LEGAL GUARDIAN: ______

Carrie Heller, M.S.W., L.C.S.W.

206 Rogers St. N.E. suite 214

Atlanta, GA.30317

404-549-3000

Photography & Videography Release Form

I, (please print your name here)______, grant Carrie Heller and the Circus Arts Institute, LLC permission to take photographs and/or videography of myself and/or my child, or other family members under the age of 18 listed below:

______

to be used for the following:

□ Advertisement (to include but not limited to:

Facebook/ website/brochure/flyers/advertisements)

□ Educational (to include but not limited to: presentations, learning and teaching)

Permission is granted by:

______

Signature of student and/or parent/guardian Date