Kids Community Music Camp at St. John’s

*Student's Name

*Street Address

*City, State, Zip

*Grade in School (2021-2022)

*Age (as of 8/9/21)

*Date of Birth (including year)

*School Currently Enrolled In

*Parent/Guardian/Caregiver Name

*Relationship to Child

*Parent Cell Phone

Parent Home Phone

*Parent/Guardian Email Address

Ethnicity
Black/African-AmericanIndigenousLatinoLatinxCaucasianAsian/Pacific IslanderOther/Multi-EthnicChoose Not to Disclose

Does your household receive federal or state benefits such as SNAP, or other State Assistance?
YesNoChoose Not to Disclose

*Who will be picking up your student?

*Students must be picked up every day by 3:15 p.m. by a parent, guardian, or authorized caregiver age 18 or older. If different adults will be picking them up on different days, please list all names, and include cell # for those not otherwise listed here. Any child who is picked up later than 3:30 p.m. without sending prior notice to camp staff via phone call or text will be subject to removal from the remainder of camp.

*Other Parent/Guardian or Emergency Contact Name #1

*Relationship to Child

*Cell Phone

Home Phone

*Other Parent/Emergency Contact Email Address

*Emergency Contact Name #2

*Relationship to Child

*Cell Phone

Home Phone

*Emergency Contact 1 Email Address

Please list any medical issues, medications, food allergies:

A parent or guardian must read and sign the following waivers.

For Emergency Treatment

I, the parent/guardian, authorize Music at the Red Door’s Kids Community Music Camp program to arrange for transportation in case of accident or acute illness in the event it is not possible to receive instruction from this child’s parent/guardian. I also consent that a licensed physician may administer medication and perform any necessary treatment for the preservation of this child’s health and well-being. I understand that any cost incurred for treatment of sudden illness or accident shall be the responsibility of the parent/guardian and not the Music at the Red Door’s Kids Community Music Camp program.

General Release of Liability

I, the parent/guardian, hereby assume full responsibility for any bodily injury and property damage while my child is using any premises, facilities, and equipment associated with the Music at the Red Door’s Kids Community Music Camp. I further agree to hold harmless the Music at the Red Door’s Kids Community Music Camp program and their partners, directors, employees, and volunteers from any and all claims that may result from any action for damages, including but not limited to such claims that may result from injury, accident or otherwise, during or arising in any way from said child participating in the Music at the Red Door’s Kids Community Music Camp.

Community Field Trips

I, the parent/guardian, give permission for this child to attend any field trip or event associated with the Music at the Red Door’s Kids Community Music Camp program as long as proper notice is given to the parent/guardian. I, the parent/guardian, give permission to the Music at the Red Door’s Kids Community Music Camp to provide transportation and meals.

Media Release

I, the parent/guardian, hereby consent to the use of this child’s first name, likeness and speech in any audio tape, video tape, film or photograph made in association with the Music at the Red Door’s Kids Community Music Camp. I, the parent/guardian, authorize Music at the Red Door’s Kids Community Music Camp to use photos and images of this child for educational and marketing purposes online and in marketing material. I, the parent/guardian understand that this child’s participation in these purposes offers no compensation and that this child’s first name, likeness and speech may be edited, produced, and recorded for duplication and distribution as the Music at the Red Door’s Kids Community Music Camp deems appropriate.

Assessment Release

I, the parent/guardian, hereby give consent to the Music at the Red Door’s Kids Community Music Camp program to interview this child before and after camp and gather any other applicable information as part of the Music at the Red Door’s Kids Community Music Camp’s program assessment.

COVID-19 Release

While Music at the Red Door Kids’ Community Music Camp staff and volunteers have designed camp with many safety and preventative measures, it is impossible for us to guarantee that a child or his/her household members will not become exposed to or infected by COVID-19 as a result of the child’s camp participation, because there is risk involved in all contact between people of different households during the pandemic. By signing this release, the parent/guardian agrees not to hold the camp or anyone who is working for or participating in the camp responsible should a COVID-19 exposure or infection occur at camp.

I, this child’s parent/guardian, understand that Music at the Red Door’s Kids Community Music Camp has put in place numerous preventative measures and enhanced cleaning protocols to reduce the likelihood of spreading COVID-19 at camp. I also understand that Music at the Red Door’s Kids Community Music Camp cannot guarantee that this child will not become infected with COVID-19 while participating in the camp, and that his/her participation could increase his/her risk of contracting COVID-19.

I, the parent/guardian, assume the risk that this child and members of his/her household may be exposed to or infected by COVID-19 as a result of attending Music at the Red Door’s Kids Community Music Camp. I understand that exposure to or infection with COVID-19 at camp may result from actions, omissions, or negligence of myself, this child and others, including, but not limited to, camp employees, volunteers, other campers and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injuries to my child, myself, and other household members (including, but not limited to, personal injury, disability or death), illnesses, damages, losses, claims, liability, costs or expenses, of any kind (collectively, “Claims”), that I, this child and our household may experience or incur in connection with my child’s attendance at Music at the Red Door’s Kids Community Music Camp. On my behalf, and on behalf of this child, I hereby release, covenant not to sue, discharge, and hold harmless Music at the Red Door’s Kids Community Music Camp’s employees, volunteers, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions or negligence of Music at the Red Door’s Kids Community Music Camp, its employees, volunteers, agents, and representatives, whether a COVID-19 infection occurs before, during or after this child’s participation in Music at the Red Door’s Kids Community Music Camp.

*Please check this box to indicate your acceptance of the above terms and conditions.
I agree to the terms outlined above.

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