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NOTE: Cancellation fees on appointments apply, if an appointment is not canceled 72 hrs prior to your scheduled time.
Here are 2 forms you may need:
Form1: General Release Form
Parent(s)/Guardian(s) Name(s)’:
Address
Home phone numbers: - Mother Father
Work phone
Cell phone
Email Address
How did you hear about Lets Jam Percussive & Creative Movement Program?
Select one...
Referral
Google search
Community event
Child's age
Select one...
1-4
5-8
9-12
13-16
17-20
21-24
25-29
30+
Please indicate which exceptionality your child has:
Autism
Emotional Distrurbance
Multiple Disabilities
Speech or Language Impaired
Health Impaired
Deaf-Blindness Hearing Impairment
ADD/ADHD
Developmental Intellectual Disability
Specific Learning Visual Impairment Disability
Other
Not identified
Please check box of parent concerns:
Social skills
Listening skills
Behavior
Gross skills
Fine motor
What are your child's strengths?
Thank you! Your submission has been received!
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Form 2: “PHOTO & VIDEOTAPE” RELEASE
!, (your name below)
hereby give Let’s Jam Percussive & Creative Movement and its representatives permission to photograph and/or videotape my son(s)/daughter(s) in conjunction with any activity associated with Let’s Jam’s musical programs. I also hereby transfer to Let’s Jam Percussive & Creative Movement all copyright and other interests in photographs and/or videotape taken during the above-mentioned activities. I also hereby grant royalty-free permission, including non-exclusive world rights in all languages, to reproduce in all formats including but not limited to print, electronic, and/or CD-ROM, to reproduce and include my son’s/daughter’s likeness for promotional purposes of Let’s Jam Percussive & Creative Movement. I understand and agree that these materials will become the property of Let’s Jam Percussive & Creative Movement, and will not be returned. I also waive the right to inspect or approve the finished promotional product. I hereby hold harmless and forever discharge Let’s Jam Percussive & Creative Movement from all claims, demands and causes of action which I, my heirs, representatives, executors, and any other person on my behalf have or may have by reason of this authorization.
By putting your name and date below and clicking "Submit" you are legally agreeing to the statements before.
Date
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