My City Kitchen, Inc.

Kids Cooking Program

6 Research Dr

Shelton, CT 06484

Phone: 475-269-2984

E-mail:

Website: Facebook: My City Kitchen& MCK Gourmet

COOKING CLASSES REGISTRATION FORM

Date: / /__ Funding Agency or Sponsor:______Class Date: ______

Name: ______Age: _____Grade: ____ Date of Birth: ______Gender: Boy / Girl__

Full Address: ______

Phone# / Cell Number: ______School: ______

Parent/Guardian Name: ______Email:______

Parent/ Guardian Address: ______

ANY KNOWN FOOD ALLERGIES: ______

In the event that I the parent / Legal guardian is unable to pick up the child. Please grantpermission to release (child’s name) ______to:

Name: ______

Relationship: ______

Phone Number: ______

Please note that anyone other than the parent picking up a child MUST

Provide proof of identity or child WILL NOT be released.

TO APPLY FOR A SCHOLARSHIP PLEASE FILL OUT THIS SURVEY

□ I agree to participate in this voluntary survey □ I decline to participate in this voluntary survey

Ethnicity: □ American Indian □ Asian □ Black □ Caucasian □ Hispanic □ Other ______

Members of Household: □ Adults:______□ Children: ______

Head of Household: □ Married □ Single □ Single Female Head of Household

□ Single Male Head of household □ Grandparent / Relative or Guardian

Estimated Annual Gross Income:

□ Equal to or less than $20,000 □ $20,001 to $35,000 □ $35,001 to $50,000 □ Greater than $50,000

PARENT / GUARDIAN CONSENT & RELEASE

I, the custodial parent or legal guardian of the child named above, hereby consent to the child’s participation in

My City Kitchen, Inc. cooking program. I hereby agree and acknowledge that the program may include, among

others any one or more of the following activities: preparing food and recipes; learning basic cooking

techniques; nutrition lessons; and a field trip to a local farm, farmers market or grocery store. While such

activities will be conducted under the supervision of a professional chef, such activities may involve the use of a

microwave and other potentially dangerous items.

I hereby give My City Kitchen, Inc. permission to use the child’s name, voice, likeness and biographical

material about the child in connection solely for promotion of its products and services, for both broadcast and

non-broadcast purposes.

I, for myself and the child hereby release My City Kitchen, Inc. and their respective affiliates from any and all

liability, loss, damage, cost of expense of any nature whatsoever, as a result of the child participation in the

program.

I, on behalf of the child hereby authorize the administering of BASIC first aid procedures as may be deemed

necessary in the event the child is injured at or in connection with participation in the program. In case of a

major accident, injury or illness requiring immediate medical attention, I authorize My City Kitchen, Inc. or

such other individuals conducting the class, to act on my behalf, provided that they make diligent efforts as the

nature of the emergency permits to notify me at the phone number indicated above.

Child Name:______

Parent / Legal Guardian Name: ______

Date: ______

Signature of Parent / Legal Guardian: ______