Kids Community Music Camp at St. John’s

*Child's Name

*Street Address

*City, State, Zip

*Grade in School (2019-2020)

*Age

*Date of Birth (including year)

*School Currently Enrolled At

*Parent/Guardian Name

*Relationship to Child

*Cell Phone

Home Phone

*Parent/Guardian Email Address

Ethnicity
Black/African-AmericanAmerican IndianLatino AmericanCaucasianAsian/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

*Is after-care necessary for your child to participate in this camp? After-care additional cost: $10/child.
YesNo

What time would you be able to pick up your child if they participate in after-care? (CANNOT BE LATER THAN 5:15 PM)
Any child that is picked up later that 5:15pm will be subject to removal from camp.

*Other Parent/Guardian or Emergency Contact Name

*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:

*Students must be picked up by a parent or an authorized guardian over the age of 18.

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 of while using any associated premises, facilities, and equipment hereon associated with the Music at the Red Door’s Kids Community Music Camp. I further agree to hold harmless the Music for 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 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 likeness and speech in any audio tape, video tape, film or photograph made in association with the 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 for educational and marketing purposes online and in marketing material. I, the parent/ guardian understand that any participation offers no compensation and that my/my child’s name, likeness and speech may be edited, produced, recorded for duplication and distribution as the Music at the Red Door’s Kids Community Music Camp deems appropriate. Note: Per Safe Church policies, Music at the Red Door's Kids Community Music Camp promises to never publish your child's name or contact information on any educational or marketing materials in association with his/her image.

Assessment Release

I, the parent/guardian, hereby give consent to the Music at the Red Door’s Kids Community Music Camp program to interview my child pre and post camp and any other applicable information as apart 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.

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