Art Therapy Application

All application information is kept confidential. Please answer to the best of your ability.

PARENTS:  if you are completing this form for a child please complete it as if you are the child.

Applicant Information
Name *
Name
Age *
Age
Phone *
Phone
Address
Address
Emergency Information
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Physician Name *
Physician Name
Physician Number *
Physician Number
Additional Questions
The following questions are to get to know you better. Please answer them to the best of your ability. *
The following questions are to get to know you better. Please answer them to the best of your ability.
All information is kept confidential.
I feel confident in myself.
I engage in new and challenging activities.
I am satisfied with my social skills.
I have a network of people I can rely on for support.
I feel like I am capable of expressing my personality, thoughts, and emotions.
Waiver of Liability *
In consideration of participating in Studio E: The Epilepsy Art Therapy Program, and by signing this agreement, I hereby for myself, my heirs, my executors and administrators, waive and release any rights, claims and causes of action against the organizers, sponsors and any others connected with the Studio E: The Epilepsy Art Therapy Program, their representatives and successors, as a result of my involvement with said events. I attest and verify that I am medically able to participate and assume all risks of participating in this event. In completing this release, I further acknowledge and represent that I HAVE READ THE FORGOING Waiver of Liability Agreement, UNDERSTAND IT AND SIGN IT VOLUNTARILY as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreements have been made; and I EXECUTE THIS RELEASE FOR FULL, ADEQUATE AND COMPLETE CONSIDERATION FULLY INTENDING TO BE BOUND BY SAME. I hereby further agree that this Waiver of Liability Agreement shall be constructed in accordance with the laws of Montgomery County, Ohio. I have read and fully understand the foregoing and certify and represent that the information provided is true.