Virtual Holiday Special 2022

Tuesday, December 20th- Thursday, December 22nd, 2022

Tuesday, December 20th- Cooking class 1pm-3pm

Wednesday, December 21st- Adult Art Class 10am-12pm; Youth Art Class 1pm-3pm

Thursday, December 22nd- Gary the Great Interactive Magic Show at 5pm

We are excited to bring a Holiday Special this year! There are a few different activities that are going to be a lot of fun throughout the week!

Thank you for your interest! If you have any additional questions please contact miriam@epilepsynorcal.org

Participant Information

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Main Email

Phone number

Gender

Female	Male	Non-binary
Prefer not to say

Participant's Age

Does the individual have any food allergies?

Yes

Please list all known allergies here

Please provide information on any chronic physical problems or pertinent developmental information or any special accommodations needed

Parent Name

Emergency Contact Information

Emergency Contact's First Name	Emergency Contact's Last Name
Relationship to Participant	Contact Number

Payment

Amount is Free of Charge

Informed Consent and Acknowledgement

I hereby grant to the Epilepsy Foundation of Northern California the absolute and irrevocable right and unrestricted permission to use my or my family’s name, likeness, image, voice, and/or appearance as such may be embodied in any photos, video recordings, audiotapes, virtual programs, digital images, and the like, taken or made on behalf of the Foundation or its partners. I agree that the Foundation has complete ownership of such material and can use said material for any purpose consistent with the Foundation’s mission. These uses include, but are not limited to, videos, publications, advertisements, news releases, Web sites, and any promotional or educational materials in any medium. I acknowledge that I will not receive any compensation for the use of such images, video, likeness, etc.

I hereby release and discharge the Foundation, and its agents, representatives and assignees from any and all claims and demands arising out of or in connection with the use of my name, likeness, image, voice and/or appearance, including any and all claims for invasion of privacy, right of publicity, misappropriation or misuse of

image, and/or defamation.

I represent that I am over the age of eighteen (18) years and that I have read the foregoing and fully understand its contents. This release shall be binding upon me, my heirs, legal representatives, and assigns.

This agreement is being made and entered into under the laws of the State of California and shall be governed and interpreted in accordance with the laws of said state. This agreement embodies the entire agreement of the parties (subject and photographer). No modification of this agreement shall be of any effect unless it is made in writing and signed by all of the parties to the agreement.

I have read, understand, and agree to the above. I do not grant permission.

Participant's Name

Parent/ Legal Guardian Name

Parent/ Legal Guardian E-Signature

Date

Authorization

I do hereby authorize any medical personnel having records or confidential information regarding my child to disclosure such information to the Epilepsy Foundation of Northern California if deemed necessary.

Parent/ Legal Guardian Name

Parent/ Legal Guardian E-Signature

Date