Student Name *

First Name

Last Name

Student Phone

(###)

###

####

Student Birthdate *

MM

DD

YYYY

Student Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Guardian Name *

First Name

Last Name

Parent / Guardian Phone *

(###)

###

####

Photography / Media Release

I give permission to use my student's likeness in a photograph, video, or other digital media on our website, social media, emails or other print media.

I do not give permission

Liability Release *

I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold the Flow Loves You Foundation, its leaders, employees, and volunteers liable for damages, losses, diseases, or injuries incurred.