2525 Ontario Road, NW
Washington, DC 20009
Phone: 202-797-2145
(for students 18 and under)
(child’s name) (month/day/year)
and hereby give my consent for my son/daughter to participate in any Sitar Center sponsored activity. I give The Sitar Center the right to use photographs and images of my child for the Sitar Center publications, electronic media and materials. By my signature I acknowledge that neither the Sitar Center, nor any of its staff, nor volunteers will be held liable in the event of accident or injury to my son/daughter. The Sitar Center will take every reasonable precaution to provide for the safety of the children while participating in Sitar Center activities, which sometimes includes car or van travel within the Washington, DC metro area, but The Sitar Center is not responsible for children and volunteer contact outside the authorized Sitar Center sponsored activities Please call the Sitar Center, at the number listed above, if you have any questions regarding sponsored versus non-sponsored programs.
Parent/Guardian’s Signature_________________________________Date____________
Parent/Guardian’s Signature_________________________________Date____________
Parent/Guardian’s Signature_________________________________Date____________
Is student taking any medication?___If yes, what medication?_______________________
Is student alergic to any medication?___If yes, that medication?_____________________
Parent’s employer_____________________________Position_____________________
Work address____________________________________________________________
Work phone___________________Fax_________________e-mail_________________
Home phone________________Emergency contact(full name)_____________________
Emergency contact phone #_____________________
I, the undersigned parent or guardian of the above named participant do hereby give my consent, in the event all reasonable attempts by the authorized medical personnel to contact me at the phone numbers listed above have been unsuccessful, for:
1. The administration of any treatment deemed necessary by a licensed physician.
2. The transfer of the participant to a hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinion of a second licensed physician concurring in the necessity for such surgery is obtained prior to the performance of such surgery.
Signed(full name)_____________________________________Date________________
Home address:________________________________Apartment #_________
City_____________State_________Zip code_______
Signed(full name)_____________________________________Date________________
Home address:________________________________Apartment #_________
City_____________State_________Zip code_______
Signed(full name)_____________________________________Date________________
Home address:________________________________Apartment #_________
City_____________State_________Zip code_______
1. I agree to assist with the program at least one hour per month
2. I agree to pay the registration fee for the semester
3. I understand that certain behaviors are inappropriate and disrespectful and that if my child is behaving in an unacceptable manner, I will be contacted. I further understand that if such conduct continues, my child will be asked to leave the program.
4. I agree to support and encourage my child by asking, each day, about his or her arts activities.
5. I agree to make sure that my child promptly turns in a copy of his/her school report card each quarter beginning with the last year’s final report card.
6. I agree to serve as a role model to all of the children at the Sitar Center
Parent/guardian signature________________________________Date________________________
Parent/guardian signature________________________________Date________________________
Parent/guardian signature________________________________Date________________________