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MIRROR Project Registration

Registration for Westwind School for Performing Arts Students 

Contact Information
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First Name
Last Name
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country

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I hereby grant Real Images, In the absolute and irrevocable right and unrestricted permission to use photos/videos taken of me or in which I may be included with others, and to use, re-use, publish and re-publish the same in whole or in part, individually or in conjunction with other photos/videos and in conjunction with any media now or hereafter known, and for any purpose whatsoever for illustrations, promotion, art, editorial, advertising, and trade, or any other purpose whatsoever without restriction.
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I give permission to Real Images and all team members affiliated with the organizations to dialogue and engage my student with mental health professionals as it relates to the topics of the MIRROR Program sessions
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give permission to Real Images and all team members affiliated with the organizations to give my student medical attention in the case of minor or major emergencies, and contact the emergency contact listed on the file associated with the school/ after-school program partnering with Real Images.

Please list any medical conditions, including food allergies, and medications workshop facilitators should be aware of: