2021 SPRING CFAC / THE ACADEMY REGISTRATION FORM

Student Name

First Name

Last Name

Student Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home County

i.e Jefferson, Oldham, Floyd. Clark, etc.

Parents Name

First Name

Last Name

Parent Email

Alternate Parent E-Mail

If you would like to list a second parent's e-mail, a work e-mail, etc.

Student E-Mail

If the student would also like to receive the newsletter with volunteer opportunities, workshops, scholarship info, etc.

Main Parent Phone

(###)

###

####

Emergency Contact Number

(###)

###

####

Student Age

Student's School

Anything else we should know?

What wait list you would like to be added to if you are selecting the wait list options. Anything else of importance (i.e allergies, special needs, pronoun preferences, etc.)

Initial to agree to the following.

My student, named below, wishes to accept the invitation into the Children’s Fine Art Classes Studio Art Program. I understand that the student named above is invited into this program because he/she has been identified as visually talented by a teacher, school official, or because his/ her art work has been identified as outstanding at the CFAC sponsored Portfolio Review. I also understand and agree that one piece of my student’s artwork, per semester, will be donated for the CFAC annual exhibit. The CFAC exhibit is an annual fundraiser for LVA, and all exhibited artwork will be for sale. LVA is not responsible for any artwork left after the last day of class. If the student is in The Academy they will place a piece in the exhibition, but it will be listed as not for sale during the exhibition. Students will have the option of selling the artwork and keeping the proceeds if they wish, but it will be up to each student. I, the undersigned, give my permission for that student to participate in CFAC or The Academy for the Fall 2018 semester, consent and authorize LVA to interview, photograph, and videotape my student and/or his/her artwork and I further consent to and authorize LVA to release, publish, exhibit, or reproduce such interviews, photographs, and videotapes for use in public relations, news articles, telecasts, press releases, or education, advertising, research at any time in any form or media, whether now known or later discovered, including but not limited to the LVA website, fundraising, or any other purpose by LVA and/or its affiliates. I release LVA, its officers and employees and sub-contractors, and any and all persons involved from any liability connected with the taking, recording or publication, release, exhibit, or reproduction of said interviews, photographs, slides, computer images, videotapes, sound recordings or any other media representation. I waive all rights on behalf of my student to any claims for payment or royalties or other compensation in connection with any exhibit, release or reproduction, televising, or other publication of these materials, regardless of the purpose of sponsoring of such exhibiting, broadcasting, or other publication irrespective of whether a fee or admission or film rental is charged. I also waive any right to inspect or approve any photo, video, film, or any other media representation taken by LVA or the person or entity designated by it. I declare that I am eighteen (18) years old or older and am legally competent to execute this release. I understand that the terms herein are contractual and not a mere recital, that this instrument is legally binding, and that I have

Order Confirmation Number