2017 Student Workshop Release Form

Student Workshop Registration Form

STEP 1 OF 2!
You must also make your payment through the Paypal button to complete the participant’s registration. Each participant must be registered independently. Spaces are filled on a first-come, first-served basis and the date/time stamp from Paypal will determine the order registrations are received.

* Indicates required field

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Phone Number *

Back-up Emergency Phone Number *

Participant's Name *

First

Last

Date of Birth *

Participant's School (If Applicable) *

Participant's Grade in Fall 2017 *

Session Selection (Classes are limited space and are issued on a first-come, first-served basis using PayPal's date/time stamp.) *

Lion's Pride Self-Defense (Grades 1-4) 11 AM-12:50 PM Lion's Pride Self-Defense (Grades 5-8) 2 PM-3:50 PM Lego Bricks-4-Kidz (Grades K-2) 10 AM-11:50 AM Lego Bricks-4-Kidz (Grades 3-5) 12 PM-1:50 PM FIRST Robotics 10 AM-11 AM FIRST Robotics 12 PM-1 PM

PHOTO / VIDEO RELEASE
I understand that by registering my child to participate in the Student Workshops I am consenting to general photography / videography while in the session. These images will be the property of Bluegrass Education and may be used for future promotional materials. They will not be sold or distributed to any parties outside of those presenting these workshops. Please check below to acknowledge that you have read and understand this statement.

Photo/Video Release *

Yes, I have read the release and understand that continuing this registration signifies my consent. No, I do not consent and hereby withdraw my registration.

INDEMNITY ACKNOWLEDGEMENT
To the fullest extent permitted by law, I shall indemnify and save and hold free and harmless the Bluegrass Education Expo, Kentucky Youth Leadership, Inc, Lion's Pride Martial Arts, Bricks4Kidz, & Yellow Wood Tutoring, their officers, employees, agents, servants and volunteers from any and all actions, claims, demands, judgments, damages, losses, and expenses, whether direct or indirect, including but not limited to attorney's fees, arising from any accident or occurrence related in any manner to the Student Workshops. I shall undertake to defend, at my own expense, any and all actions, claims, or demands brought against the afore mentioned organizations and individuals by reason of or related in any manner to the Student Workshop, and to pay, settle, compromise and procure the discharge of any and all judgments, damages, losses and expenses, including but not limited to attorney's fees. I understand and I agree to carry such bodily injury and property damage liability insurance as will protect myself and my student against any and all claims for personal injury, including death, or property damage, which may arise from or be related in any manner to the Student Workshops.

By registering my student and checking below I indicate that I am a legal parent or guardian of the participant. I also acknowledge that I have fully read, understand, and agree to all terms of the above Statement of Indemnity.

Indemnity Acknowledgement *

Yes, I have read the release and understand that continuing this registration signifies my consent. No, I do not consent and hereby withdraw my registration.

Submit