Magic Paintbrush Project Workshop
Participant Information and Consent Form

Date of Birth: (dd/mm/yyyy)
Participant Name:
Address:
city:
state:
zip:
County:
Contact Phone: (607) 123-4567
Email:
Social Security #
Medicaid #
Referring Agency
(or MSC)
Preferred Language
Residence Type
Special Concerns/Needs:
Allergies?:
Parents Name:
Participating Siblings Names and Ages:
Session Type Preferences
Preferred day and time
Preferred Media
(Session fee may vary depending on activity)
If session is with specialist please indicate the specialty:
Specialist Name:
Specialist contact phone:
What goals do you have for your workshop experience?
Do you want to be included on our mailing list for public events and workshops?
         Consent
For the opportunity to participate in a Magic Paintbrush Project workshop or any other event connected with The Magic Paintbrush Project and for other valuable consideration, I understand that by signing this release, I agree to hold harmless The Magic Paintbrush Project a program of Binghamton Imaginink, Inc, including all of its employees, managers, directors, volunteers and agents; all sponsoring organizations and any other parties connected with events and activities, singly or collectively, from any liability for any injury, harm, loss, inconvenience or damage suffered or sustained as a result of participation in one or more events or any activities associated therewith.

I understand that I will be working with volunteers from the community to create artwork which may be used to raise funds for The Magic Paintbrush Project/Binghamton Imaginink, Inc. I understand that all artwork will become the property of the Magic Paintbrush Project. I waive all claims for any compensation from the sale of artwork.

I hereby give my permission to The Magic Paintbrush Project a program of Binghamton Imaginink, Inc, to use my photograph or portion thereof, whether still or moving, my voice, and my likeness for trade, for publicity or for any other lawful manner whatsoever, hereby waiving my right to review or approve such photograph, sound recording or likeness prior to its use. Print: Signature: Date: Signature of parent if under 18: The Magic Paintbrush Project is a program of Binghamton Imaginink, Inc. a 501(c)(3) nonprofit organization. Support of our program is tax-deductible. This material represents the opinions of The Magic Paintbrush Project and Binghamton Imaginink, Inc. It should in no way be taken as general or specific medical advice. Please consult your primary care physician or other medical specialist for specific advice about your medical condition. Trademark and Copyright 2006

         


Creating Hope


The Magic Paintbrush Project Life Is... Washable!
Copyright 2006 Trademark and Patent Pending