Children /Teen Registration

Registration Form

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Registration for: *

Writing Workshop for Teens $150

Participant's Name *

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Last

Parent/Guardian's Name *

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Last

Phone Number *

Email *

Additional Info. I need to know about your child (i.e. allergies, medical needs, etc.) *

Comments *

Age *

Emergency Contact Name *

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Last

Emergency Contact Phone Number *

Address *

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Line 2

City

State

Zip Code

Country

Your payment is refundable 1 week before the start of the workshop/camp/class. After 1 week there can be no refund. There is a $25 admin. fee for refunds. If the program is cancelled your deposit will be refunded in full.

I hereby understand and acknowledge that the camps/classes/workshops held by "Muck and Gold LLC", Christine Bodwitch or Scott Gallagher may expose my child to many inherent risks, including accidents, injury and illness and that I assume all risk associated with participation and (ii) I agree, for myself and anyone entitled to act on my behalf, to hold harmless, waive and release Muck and Gold and its agents and representatives from responsibility, liabilities, demands, or claims of any kind arising out of my child's participation in Muck and Gold camps/classes/workshops.

Check box *

I agree

I give permission to Muck and Gold to use photos and videos taken in a workshop/class/camp to use in our flyers, advertisements and social media. *

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