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Program Participation Form

Participant Contact Info

Emergency Contact Info

I do hereby agree to attend and participate in program(s) and/or service(s) offered by Million Little. I understand that Million Little’s program(s) and/or service(s) do not constitute medical or psychological therapy and that Million Little does not offer any medical or psychological diagnoses. I hereby release Million Little, its directors, officers, employees, associates, and contributors from liability from any injury, loss, or theft incurred by me during the course of the program(s) and service(s) unless caused by the gross negligence or willful misconduct of Million Little. I hereby agree for my artwork, data, and documentation to be used in Million Little’s publication and educational research; provided, that neither my name nor identity will be revealed in the presentation of such artwork and documentation unless I expressly give permission to do so. I further understand that all reports, studies, information, data, statistics, forms, designs, plans, procedures, systems, and any other materials produced during Million Little’s program(s) and/or service(s) shall be the property of Million Little.

My signature indicates that I completely understand and agree to the above statement.

Filling out the field below will serve as your signature:

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