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Rogue Gallery & Art Center

Emergency Release Information

Required for all children attending classes, camps or workshops:

Student Name:________________________________________

Birth date:_________________________________Age:______

Parent Name: ________________________________________

Emergency Phone/cell phone:___________________________

Alternate Phone:______________________________________

Relationship:_________________________________________

List allergic reactions and severity:______________________

____________________________________________________

____________________________________________________

Physician’s Name: ____________________Phone:__________

Please read and sign below:

Should any injuries occur during or as a result of participation in any

Rogue Gallery & Art Center program, I agree to indemnify and hold

Harmless Rogue Gallery & Art Center and all employees, instructors,

and volunteers associated therewith.

I give permission to seek medical attention for my child in case of accident

or emergency. I understand that every effort will be made to contact myself

or the emergency contact person in the event of a medical emergency.

I authorize _________________________________________(name/phone) to pick up/ deliver my child to RG&AC. I will provide written permission for any other

Adult to pick up my child.

Signature:________________________________Date:_____________________

Please observe drop-off and pick-up times. We do not have the staff to adequately

supervise your child outside of class times.  

Sometimes we photograph classes for publicity purposes; registration acts as permission to use your likeness unless we are notified otherwise in writing.