GENERAL REGISTRATION

TEACHING CIRCLE REGISTRATION FORM

Parent/Guardian Name

Phone

Participant Name(s)

Address

EMERGENCY CONTACT

Contact First Name

Contact Last Name

Contact Phone Number

Please list any additional infomation you'd like to include about your participant (Allergies, medication, diagnosis etc.)

MEDIA RELEASE

Teaching Circle, LLC uses images of Participants in our programs for private newsletters sent directly to other Teaching Circle, LLC parents and public use including, but not limited to, Facebook, Twitter, lnstagram, social media platforms and other printed advertisements. Teaching Circle, LLC also shares images with funders and community partners for advertising and publicity purposes.

I hereby grant Teaching Circle, LLC. permission to use my child's likeness for publicity purposes on public websites including, but not limited to, Facebook, Twitter, Instagram, websites associated with Teaching Circle, LLC, community partners, and other printed media. I understand and agree that Teaching Circle, LLC does not have the ability to control who may have access to any such materials once they are made available by Teaching Circle, LLC (or any person authorized by or acting on behalf of Teaching Circle, LLC ) and I hereby release Teaching Circle, LLC from any liability arising out of or related to the use of my child’s likeness.

I do not consent to any use of my child's likeness by Teaching Circle, LLC.

TEACHING CIRCLE REGISTRATION FORM

EMERGENCY CONTACT

MEDIA RELEASE

Thank you for submitting!