MODE MUSIC STUDIOS 2019 SUMMER CAMP REGISTRATION (AGES 6-11)

Mode Music Studios
3805 Delridge Way SW
Seattle WA 98106
http://www.modemusicstudios.com

STUDENT INFORMATION

First Name *

Last Name *

Gender

Birth Date * +

Grade (in the Fall) *

ADULT PRIMARY CONTACT

PRIMARY ADULT Relationship to Student: *

Mother

Father

Guardian

Other Other

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Alternate Phone

Email Address *

SECONDARY ADULT Relationship to Student:

Mother

Father

Guardian

Other Other

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

I agree that I am responsible for paying the full amount of the camp tuition before the first day of camp. If the tuition is not paid in full, I understand my spot will be freed up for another camper. *

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EMERGENCY INFORMATION

We want to create a successful experience for your child. Please explain any serious health condition (for example: diabetes, severe allergies, epilepsy/seizure disorder, severe asthma or cardiac/heart conditions) or learning/behavioral challenges. *

MEDICAL DETAILS

Any medication brought to class/camp should be kept in the student’s backpack.* Let us know if alternative arrangements should be made for any reason. Refrigeration will not be available. If your student cannot self-administer medication, you must make arrangements for a person known to the child to come to camp or class and administer medication. Please advise the camp or class teacher of the person’s name and arrival time in advance. If your child needs prompts to take medication, or needs to report on medications taken during class/camp, please make arrangements to have your child carry a cell phone. Instructors cannot be responsible for administering or monitoring student medication.

Please list any medications your child currently takes:

	Name	Dose / Frequency	Taken During Class / Camp	Will Self-Administer
1	Name	Dose / Frequency	Taken During Class / Camp	Will Self-Administer
2	Name	Dose / Frequency	Taken During Class / Camp	Will Self-Administer
3	Name	Dose / Frequency	Taken During Class / Camp	Will Self-Administer
4	Name	Dose / Frequency	Taken During Class / Camp	Will Self-Administer

ALLERGIES

Please list any allergies about which our staff or medical personnel should be aware: *

CHOOSE A 9:00AM - 11:30 PM ROCK BAND CAMP @ $350 (with a Saturday 5pm performance at the Skylark)

9:00AM - 11:30PM ROCK BAND CAMPS *

OR CHOOSE A 9:00AM - 12:00 PM THEATER / DANCE CAMP @ $225 OR 10:00AM -3:00 PM MUSIC VIDEO CAMP @ $300 (+ $15 materials fee)

9:00AM - 12:00PM THEATER / DANCE CAMPS *

MAKE IT AN ALL-DAY CAMP? ADD A 12:30-3:30 CAMP $150 extra ($225 for a PM half day)

You can add either a theatre camp or dance camp for only an additional $150 to make a full day! indicate below which camp you'd like to add. *

REGISTER FOR BEFORE / AFTER CARE

Would you like to register for BEFORE care (8-9 am)? *

If yes, please select weeks below:

Would you like to register for AFTER care (3:30 - 5:30 pm)? *

If yes, please select weeks below:

PAYMENT

INDICATE THE FULL AMOUNT PAYMENT YOU'RE MAKING FOR HALF DAY OR FULL DAY, AS WELL AS ANY BEFORE / AFTER CARE. *

PHOTO / VIDEO RELEASE

I hereby grant and authorize Mode Music and Performing Arts (MMPA) the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration.

This authorization extends to all languages, media, formats and markets now known or later discovered.

This authorization shall continue indefinitely, unless I otherwise revoke this authorization in writing.

I waive the right to inspect or approve any finished product in which my likeness appears, including written or electronic copy.

I agree that I have agreed to this release without being compensated. I waive any right to royalties or other compensation arising or related to the use of the photograph.

I understand and agree that these materials shall become the property of MMPA and will not be returned.

I hereby hold harmless and release MMPA from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

*

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COMPLETION

I, the undersigned parent/guardian of the registrant, acknowledge the possibility that participation in Mode Music Studios activities could result in physical injury to the registrant. I hereby release, discharge and agree to hold harmless Mode Music Studios, its officers, directors, employees, agents and affiliates from any and all claims arising from or related to the registrant’s participation in Mode Music Studios activities. I further authorize Mode Music Studios staff to obtain medical care for my child in case of an emergency. I certify that I have read, understood, and agree to the above conditions, and that the information provided is complete and accurate to the best of my knowledge. *EpiPens will be kept with the First Aid kit at camp. In cases of severe allergic reaction, instructors are trained to administer EpiPen to outer thigh, call 911 and then call parents. Please remember to pick up your EpiPen from staff on the last day. *

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