Bindlestiff's Summer Cirkus 2022 Hudson Youth Center
Monday August 8  - Friday August 12: 9am - 12 pm Hudson Youth Center 18 S 3rd Street
Sankofa Hudson Black Arts & Cultural Festival Saturday August 13: 1pm - 3pm
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Email *
Child's Name First, Last *
Child's Date of Birth: mm/dd/yyyy *
Child's Grade *
Parent  / Guardian Name *
Address *
Mobile Phone / text *
Emergency Contact Name *
Emergency Contact Phone *
Name and number of anyone else who has permission to pick up your child: *
PERMISSION NOTICES
THERE ARE THREE SEPARATE PERMISSIONS. PLEASE COMPLETE ALL THREE.
PERMISSION NOTICE 1:  I  understand that Bindlestiff will document classes for grant recording, archival, and promotional purposes, using photo, video, or audio recording and understand that this may include likenesses of my child. *
Required
PERMISSION NOTICE 2: Bindlestiff may use photo, video, or audio recordings, which may include likenesses of my child, in appropriate and safe social media platforms. *
PERMISSION NOTICE 3: By signing this form, I declare that I am the legal parent/guardian of the minor child listed above and authorized to grant such permission. *
Today's Date: *
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A copy of your responses will be emailed to the address you provided.
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