Bindlestiff's Summer Cirkus 2022 Stilts with Kaisokah Moko Jumbies

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Monday August 8 - Friday August 12: 2pm - 5pm Hudson Youth Center 18 S 3rd Street
Sankofa Hudson Black Arts & Cultural Festival Parade Saturday August 13: 1pm - 3pm

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Child's Name First, Last *

Child's Date of Birth: mm/dd/yyyy *

Child's Grade *

Parent / Guardian Name *

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Emergency Contact Name *

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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. *

YES

必填

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. *

YES

WITH RESTRICTIONS - I WILL CONTACT stephanie@bindlestiff.org WITH MY CONCERNS

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. *

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