Medical Release


Medical Release and Waiver

To be completed and brought to class








Cell Phone:



Emergency Contact:

Emergency Contact:

Please list any personal health issue that may require special attention:



How did you find The Loft Jewelry Studio:




Medical Treatment Release:

To the extent permitted by law, I hereby agree to release, indemnify, defend and hold harmless on behalf of myself, The Loft Jewelry Studio LLC, Nohline L’Ecuyer, Gerald L’Ecuyer, Tembo Tusk Inc, 918 Lincoln LLC and any of it’s employees, whether paid or volunteer from and against any and all liabilities, claims, penalties, losses or expenses (including attorneys’ fees), of any kind or nature whatsoever, whether related to bodily injury, property damage or any other form of injury or loss to myself, cause by any negligent act or omission of The Loft Jewelry Studio LLC, Nohline L’Ecuyer, Gerald L’Ecuyer, Tembo Tusk Inc, 918 Lincoln LLC or outside instructor, arising out of or in any way related to participation in the activity in which I am participating.  I am acknowledging that the activity to this release can be hazardous and as a result of signing below, I am accepting those risks for myself.

I have read and understand the above policy and agree to comply with its provisions. In the event of injury, illness or accident, I hereby authorize the The Loft Jewelry Studio LLC to call 911 to provide urgent care to myself.

________________                                                          _______________

Initials                                                                                Date

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Release for Media Recording:

I, the undersigned, do hereby consent and agree that The Loft Jewelry Studio LLC, its employees, or agents have the right to take photographs, videotape, or digital recordings of me during the time of class for which I am currently enrolled and to use these in any and all media, now or hereafter known, and exclusively for the purpose of marketing.

I further consent that my name and identity may be revealed therein or by descriptive text or commentary.

I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.

I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

________________                                                       _______________

Initials                                                                             Date



I, ______________________________________ , have read, understood and hereby agree to the terms and conditions of this form.


_______________________________________         ____________

Signature                                                                        Date


Student Interest Form:

Please add any comments and list other workshops you would like to see us offer in the future. Or refer a friend who may be interested in jewelry making by writing their email here! _________________________________________________________________________________








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