PSL | Tuesday Studio Series Form

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First name*:

Last Name*:

Email Address:

Phone Number:

Age*:

Birthday*:

Parent/Guardian Name:

Parent/Guardian Email:

Parent/Guardian Phone Number:

Emergency Contact Name*:

Relation to Student*:

Emergency Contact Number*:

Does this student have allergies?*:

If yes, please list below:

Does this student have seizures*:

If yes, please describe and list seizure protocol:

Will this student be independent in class? Please provide any information that would help us support this student:

I DO consent to and authorize the use and reproduction by PSL Services / STRIVE of any and all photographs and any other audio/visual material taken of participants for promotion materials, educational activities, and an/or exhibitions*:

Signature of student if over 18, or guardian*:

Date*: