myCIA

Student First Name:

Student Preferred Name:

Student Middle Name:

Student Last Name:

Is this registration for an adult or young artist?

Please enter the student's age:

Student Birthdate (mm/dd/yyyy):

Student Email:

Student/Parent Cell Phone:

Student/Parent Home Phone:

Home Address Line 1:

Home Address Line 2:

Zip Code:

City:

State:

Are you an educator looking to receive CEUs?

What grade is the student currently in?

What school does the student currently attend?

Parent First Name:

Parent Last Name:

Parent Email:

Parent Cell Phone:

Parent Home Phone:

Is the Parent Home Address the same as the Student Home Address?

Home Address Line 1:

Home Address Line 2:

Zip:

City:

State:

Has your child taken classes through the Continuing Education department at CIA before?

Have you submitted a young artist medical form for your child within the last year?

Photo release:

Young Artists Medical Authorization Form

Continuing Education + Community Outreach

Please complete all fields. All information is confidential and used only in the event of an emergency. By completing this form you are agreeing to the following:

I consent to enter my child in the programs offered by the Cleveland Institute of Art. I agree to indemnify and hold harmless the Cleveland Institute of Art, its Board of Directors and all individual employees, administrators, teachers and volunteers from  any claims, judgements and liability for any injury or loss due to my child’s participation in the programs.

Emergency Contact Full Name:

Emergency Contact Relationship to Student:

Preferred Contact Method:

Cell Phone:

Home Phone:

Work Phone:

Please list any known student allergies:

Please select one of the following:

Please indicate alternative actions you would like CIA to take in the event of an emergency:

Granting Consent

I hereby give my consent that the following medical care providers and local hospitals be called in the event reasonable attempts to contact me have been unsuccessful. This consent is for (1) the administration of any treatment deemed necessary by a licensed physician and (2) the transfer of my child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concur in the necessity for such surgery is obtained prior to the performance of the surgery.   

List all facts concerning the child’s medical history, including allergies, medications being taken, and physical impairments to which any physician should be alerted:   

Select Young Artist Course(s):

Select Adult Course(s):

Click 'ADD THIS COURSE' to add it to your shopping cart. Then click 'PROCEED TO CHECKOUT'. Selecting 'UPDATE' will remove the course from your account.

My course(s):