Chemistry in Cosmetics Summer Program

Is the participant under 18 years old? * Yes
No

(If under 18) Parent's First Name

(If under 18) Parent's Last Name

Registrant First Name (point of contact) *

Registrant Last Name (point of contact) *

Email *

Address *

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Emergency Contact Name

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Emergency Contact Phone

Emergency Contact Alternate Phone

Is there anything we need to know or any accommodations that your child might require?

Legal Guardian Certification *

I am allowing my minor child/ren listed below to participate in the program listed above, which will be facilitated virtually by the Housing Opportunities Commission of Montgomery County (HOC). I hereby certify, under the penalty of perjury, that I am the legal guardian of the children listed in this Agreement, and that I have the authority to sign this Agreement on their behalf. I agree that participating in the program is a benefit to me and my children and, in consideration of this benefit, I am signing this Agreement on behalf of myself and my children.

I acknowledge receipt of HOC's Terms and Conditions for participation. *

Media Release Acknowledgment

HOC requires all participants to either accept HOC's Media Release ("Media Release") or to opt out of the Media Release. If you want to opt out of the Media Release, please complete this form. If you do not opt out, then by submitting this form, you are accepting the Media Release for yourself and the participants listed in this form.

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