CONSENT FORM Before working together, please fill out the following consent form. Today's Date * MM DD YYYY Parent or Guardian's Name * Minor's Name * Age * Date of Birth * MM DD YYYY Gender ID * she/hers, he/him, they/them, other Address * Phone * (###) ### #### Email * Emergency contact person (name, relationship, contact info) * I give permission for my child (myself) to take part in the activities provided by Keyhole Therapeutic Arts LLC and for the information to be held and used by the Keyhole Therapeutic Arts LLC. I give permission for Keyhole Therapeutic Arts LLC to use photo/video footage taken during the activities for promotional purposes such as displays / DVD presentations of our work. I give permission for medical attention to be sought in case of emergency. I have carefully reviewed and read the privacy policy of Keyhole Therapeutic Arts LLC and had the opportunity to understand its contents. By providing my consent, I acknowledge and agree to the terms outlined in the privacy policy . * I consent Thank you for submitting your consent form, we looking forward to working together.
