Kids Summer Community Music Camp at St. John’s

*Student's Name

*Street Address

*City, State, Zip

*Grade in School (2022-2023)

*Age

*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: Please select from this list. If your racial / ethnic or multi-racial / ethnic identity is not noted, please feel free to type in your own information.

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.

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

I agree to the terms outlined above.

Enter the text you see above

Δ