Towne Lake Academy ASP Empowerment Class

Student's Name

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Last

Grade

School Location

TLA South Campus – Mondays – 3:00PM – 4:30PM
TLA North Campus – Fridays – 3:00PM – 4:30PM

Parent/Guardian's Name

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Last

Phone

Email

With your permission, we would love to capture and share moments from our program to showcase our activities. Photos and videos will be used in marketing materials, including our website, social media, and flyers. Do you consent to your daughter being photographed and filmed during class for marketing and promotional purposes of Shining Inspirations Inc.

Yes, I consent to my daughter’s picture and video being captured and shared for these purposes.
No, I do NOT consent.

I understand Shining Inspirations Inc. is not a Towne Lake Academy program. This program has inherent risks for student injury and as the parent/legal guardian, I acknowledge and assume the responsibility of potential injury to my child. As the parent/legal guardian, I do not hold Towne Lake Academy responsible for any liabilities, judgements or damages as a result of participating in this program.

I understand and agree.
No, I do not agree.

Is there anything specific about your daughter that you'd like us to know to help provide her with the best program experience? Additionally, are there any topics or areas you'd like us to cover in class?

By signing your name below, you are providing an electronic signature, which holds the same legal effect and binding power as a handwritten signature, agreeing to all terms stated above.

Clear Signature

Shirt Size

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us hold including

Stripe Credit Card