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.
Essay Questions
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, Lundbeck, 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 the State of Illinois. I have read and fully understand the foregoing and certify and represent that the information provided is true.