Collaborative Models Workshop Information Form

Name:_______________________________

Address:______________________________ _____________________________________ Email:________________________________

Waiver Information: Please provide information regarding participant's medical history, including all drug and food allergies, pre-existing illnesses, physical, behavioural, emotional concerns. If there is nothing to report/document, please write n/a: ____________________________________________________________________________________________________________________________________________________________________________________

Medical Treatment Authorization: I give permission to CPAMO to arrange any emergency medical care including hospitalization/transportation, if necessary. All participants are responsible for their own medical coverage. I hereby release CPAMO from all liability and claims arising in relation to any matter including personal injury or damage to/loss of property, regarding participation in any activity or otherwise and hereby indemnify CPAMO from and against such claims.

Photo Permission and Release Form: I give CPAMO permission to photograph, videotape, film and/or interview and to publish said photographs, videotapes, films and/or interviews in CPAMO publications/printed material, including marketing and promotional materials, and on CPAMO official website and any other social media, including but not limited to Youtube, Facebook, Twitter. I release and forever discharge CPAMO from all actions, causes of actions, claims and demands with respect to any such use except as agreed to in writing.

Please check below:

I have provided the correct information above, read / understands all of CPAMO waiver information and agree to adhere to all mentioned above.

SIGNATURE: ____________________________________

DATE: __________________________________________

Organization__________________________________

Phone:_______________________________________

Please check where applicable

CPAMO MEMBER NON CPAMO MEMBER

1) What are you or your organization’s interest in a collaborative model?

2) Have you or your organization done collaborative work in the past

3) What are you hoping to achieve in these sessions?

4) What does the organization/artist think it can bring to a collaborative project?

5) Is your work postal code the same as your home? If no please provide your work postal code

Work Home

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