Carrie Heller

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					                            Carrie Heller, M.S.W., L.C.S.W.
                            206 Rogers St. N.E. suite 214
                                  Atlanta, GA. 30317
                                     404-549-3000

               CAMPER, FAMILY AND HEALTH INFORMATION FORM

Your assistance in supplying the following information is appreciated and will be used in
strict confidence.

Date:_____________ Your e-mail address ________________________

Client name:___________________________________Age:_________

Date of birth:____________ Sex:____ Race:____

School client attends: _________________________________________

Grade: ____ County:__________ Teacher’s name:___________________

Father’s name:______________________ Home phone:______________

Father’s employer:___________________________________________

Father’s business phone:__________ Father’s cell phone:______________

Mother’s name:______________________ Home phone:_____________

Mother’s employer:__________________________________________

Mother’s business phone:__________ Mother’s cell phone_____________

Home address (please include zip)________________________________

_________________________________________________________

Marital status of parents:___________________________ If applicable,

Dates of separation______________ and date of divorce_____________

Name of family doctor/pediatrician:______________________________

The following people are authorized to pick up my child from the Circus Arts Institute
facility:

______________________________________________________________________

                         Carrie Heller, M.S.W., L.C.S.W.
                              Carrie Heller, M.S.W., L.C.S.W.
                              206 Rogers St. N.E. suite 214
                                    Atlanta, GA. 30317
                                       404-549-3000


CIRCUS ARTS SOCIAL SUMMER INFORMATION FORM
Please fill out the following information to assist us in planning for your child's success in
the CASS program:


Please list any chronic illness/recurring medical condition, dietary restrictions or
food allergies you would want us to be aware of _________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Has your child been given a formal diagnosis? if yes, what is it? ____________________
_______________________________________________________________________


What do you hope your child will take away from his/her experience at CASS?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

What do you find helps your child to calm down when s/he is upset? (hugs from us,
hearing our voice talking calmly to them?)




What are the specific social behaviors you would like your child to work on during this
session?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________


Do we have your permission to share your name and child's name with other interested
parents? ________________


Signature of Parent or legal guardian: ______________________________________
Date: ________________________________________________________________
                              Carrie Heller, M.S.W., L.C.S.W.
                              206 Rogers St. N.E. suite 214
                                    Atlanta, GA. 30317
                                       404-549-3000

                  Conditions of Enrollment & Enrollment Agreement

I have filled out the enclosed forms and they are correct so far as I know, and the
participant herein described has permission to engage in all prescribed activities except as
noted.

The participant, his/her parents or guardians agree to abide by the rules set by CASS as
follows for the health, safety and welfare of the program. CASS reserves the right to
dismiss a participant whose conduct or influence is detrimental to the group. If this
becomes necessary, there will be no tuition refund. The Director will consult with the
parents before dismissing a participant.

CASS is not responsible for articles of clothing or personal belongings lost or damaged.
Please label all items. Do not bring valuables to the CASS facility.

Participants are expected to remain on premises unless the CASS office is notified in
writing.
In the event that a parent cannot be notified, I hereby give permission to the doctor
selected by CASS to hospitalize and secure proper treatment for the participant listed. I
agree to reimburse CASS for any and all costs it may incur for the medical treatment of the
participant.

It is expressly understood by the parent/guardian of the participant for whom this
reservation is requested that the participant is in a condition of health and soundness of
body that warrant him/her undertaking the program as outlined in the CASS literature.

I understand that all participants are supervised by staff trained in the arts of the circus. In
the event of accidental injury, I agree not to hold Carrie Heller, MSW, LCSW, CASS
individual staff members or Sensations Therafun™ liable and to pursue any claims on my
own insurance policy.

I acknowledge it is my responsibility to keep my child's record current to reflect any
significant changes as they occur, i.e. phone numbers, emergency contacts, child's health
status and who is authorized to pick up the child.


I am aware that my balance is due before June 14th. We do encourage you to return your
balance with this form.
PLEASE MAKE ALL CHECKS PAYABLE TO:
           Circus Arts Institute, LLC mail this form and payment to :
                               Circus Arts Institute
                      206 Rogers Street N.E., Suite 214
                                Atlanta GA 30317
                             PHONE: 404-549-3000

                  THERE WILL BE NO REFUNDS AFTER May 17th

I hereby enroll my child(ren) in CASS. I have read and understand this Enrollment
Agreement and all forms attached. I agree to abide by the written policies and procedures
of CASS. We agree to keep you informed of any incidents, such as illness or injury which
involve your child.



________________________          _________________________         ________________
Signature of Parent               Parent Name (Please Print)        Date


For:


_______________________________________________________________________
Participant(s) Name(s) (Please Print)
                                     Release of Liability
                                  PLEASE READ CAREFULLY

  Circus Arts Institute operates with a high level of safety consciousness, and all our teachers
and staff are trained and proficient in the arts of the circus. However the exercises and activities
performed in circus training are more dangerous than normal activity.

Please share any pre-existing medical conditions that you may have.

                                     ASSUMPTION OF RISK

   I, the undersigned Participant, or if under the age of eighteen, the Parent or Legal Guardian of
the Participant(s), do hereby acknowledge that there is the possibility of accidental or other
physical injury when participating in one or more of the Circus Arts Fitness sessions, Circus Arts
Therapy sessions, Circus Arts Social Summer, private sessions, Corporate Teambuilding and
any and all activities or programs of the Circus Arts Institute. I understand and assume the risk
of such injury to myself or to my child(ren). I represent that I or my child(ren) am/is/are/ in an
able physical condition to participate in the circus exercises and activities and that I have health
insurance in force which provides coverage in the event of any injury I or my child(ren) might
sustain. I agree to pursue any claims on my own insurance policy. I further certify that I am
willing to assume the risk of any medical or physical condition that I or my child(ren) may have.
   In signing this document, I hereby accept and assume total and complete responsibility and
liability for any such injury and all expenses related thereto. I hereby agree to hold harmless
Carrie Heller, Circus Arts Institute, LLC, Henry Finkbeiner, The Warehouse Limited Partnership,
Inc. and any and all instructors, independent contractors, or volunteers in the Circus Arts
Fitness sessions, Circus Arts Therapy sessions, Circus Arts Social Summer, private sessions,
Corporate Teambuilding and any and all activities or programs of the Circus Arts Institute
related for any injury to myself or to my child(ren) and for any loss or damage to personal
property. I hereby agree to indemnify Carrie Heller, Circus Arts Institute. LLC, Henry
Finkbeiner, The Warehouse Limited Partnership, Inc., and any and all instructors, independent
contractors and volunteers in the Circus Arts Fitness sessions, Circus Arts Therapy sessions,
Circus Arts Social Summer, private sessions, Corporate Teambuilding and any and all activities
or programs of the Circus Arts Institute related for any costs, losses or damages incurred from
any claims, actions or lawsuits (including without limitation, reasonable attorneys fees and
disbursements) by third parties which arise from or are a direct consequence of my or my
child(ren)'s actions or failures to act.

   In consideration of myself I and/or my child(ren) being permitted to participate in circus
activities, I and/or my child(ren) hereby agree that I/we have read and understand this document
and I/we agree to be bound by the terms of this document. I acknowledge that this release is
continuing in nature and shall bind me for subsequent activities, sessions or programs of the
Circus Arts Institute that I may engage in from time to time. Circus Arts Institute retains the right
to require execution of a new release in its discretion and from time to time.

PARTICIPANT(S) NAME(S) Please print ____________________________________________
DATE SIGNED: ______________
Participant Signature or PARENT/LEGAL GUARDIAN: ______________________________
                                Carrie Heller, M.S.W., L.C.S.W.
                                206 Rogers St. N.E. suite 214
                                      Atlanta, GA. 30317
                                         404-549-3000


                       Photography & Videography Release Form



I, (please print your name here)____________________________________, grant Carrie
Heller and the Circus Arts Institute, LLC permission to take photographs and/or videography of
myself and/or my child, or other family members under the age of 18 listed below:


____________________________________________________________________________




to be used for the following:

      □ Advertisement (to include but not limited to:
Facebook/ website/brochure/flyers/advertisements)
      □ Educational (to include but not limited to: presentations, learning and teaching)




Permission is granted by:



____________________________________                              _________________
Signature of student and/or parent/guardian                             Date

				
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