MMPA SUMMER 2022 CAMP REGISTRATION

Mode Music and Performing Arts
3801 Delridge Way SW
Seattle WA 98106
http://www.modemusicandperformingarts.org

We are excited to offer a fresh schedule of music, theatre, art, and dance camps that will engage students in self-expression, creativity, and community through the arts! Our 2022 Summer Camps will all take place at the MMPA Studio at 3801 Delridge Way SW. Families have the option to choose either the morning or afternoon camps, or sign up for both for double the fun!

STUDENT INFORMATION

First Name *

Last Name *

Gender

Preferred Pronouns

Birth Date * +

Grade (if applicable)

Does the student have any medical, learning, behavioral, or other special considerations/circumstances of which we should be aware? If yes, please explain: *

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CONTACT INFO

PRIMARY ADULT (to be used as the Emergency Contact)

Relationship to Student: *

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

CAMP SELECTION

MORNING CAMPS

Choose one or more weeks of 9am-12pm camps @ $300

*10% off your total order multiple class signup. Enter coupon code MULTIPLECAMP for the discount in the payment section below.*

Select the camp(s) you wish to enroll in below.

AFTERNOON CAMPS

Choose one or more weeks of 12:30-3:30 camps @ $300

*10% off your total order for multiple camp signup. Enter coupon code MULTIPLECAMP for the discount in the payment section below.*

Select the camp(s) you wish to enroll in below.

DEMOGRAPHIC INFORMATION (Optional)

Any and all demographic information is optional and any answers will be confidential. Demographic information received will be used by MMPA to receive funding to keep the cost of our programs affordable to all students. Please complete this section to the best of your ability & comfort level.

Ethnicity

Household Size

Annual Household Income

Primary Language Spoken at Home

STANDARD PHOTO/VIDEO RELEASE FOR MINORS

Mode Music and Performing Arts (“MMPA”) is requesting permission to use images and videos from our programming for the purpose of advertising and for the promotion of our non-profit to charitable foundations so we can continue to provide art classes and music lessons to all children, regardless of income. I hereby allow MMPA to use images of my child in these applications and requests. MMPA will notify me of classes that will be recorded or have screen images captured prior to the class. *

I DO give my permission

I DO NOT give my permission

COVID-19 SAFETY PROTOCOL subject to change, based on local and federal guidelines at time of camp

I, the undersigned, agree to help protect the health and safety of all MMPA students and staff by adhering to the following protocol:

- Present proof of vaccination for the attending student prior to the start of the first class.

OR

- Present proof of a negative COVID-19 antigen test prior to start of class if unvaccinated. *

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PAYMENT

*If you require a scholarship for classes, please indicate partial or full scholarship below. You will be contacted by MMPA after your registration is processed with the amount we are able to offer*

Discounts for multiple classes will be applied after checkout. Please contact 206-659-0463 or email billing@modemusicandperformingarts.org with any questions.

Please select an optional partial or full scholarship below.

Enter your coupon code here:

Current Total:

$0.00

We also offer Pay What You Can. Please enter the amount you are able to pay below, after requesting a 100% scholarship. No student will be turned away for lack of funds.

Please enter below any amount you would like to donate to our programming here at MMPA. This can help another student attend these courses, when they normally would not due to lack of funds.

CANCELLATION POLICY

If camp canceled by MMPA: Full refund. Withdrawals more than 2 weeks before the start of the program: Full refund for each individual student registration, less $50. Withdrawals 2 weeks or less before the start of the program: 50% refund. Switching between programs is allowed, based on availability. There is a switching fee of $25 per switch.

**If you are signing up to be on the waitlist for the 6/20-6/24 Ukulele 101 Camp, a $50 refundable deposit is required.**

COMPLETION

Completion of this form will automatically subscribe you to our Mode Music Studios newsletter. This is a monthly publication that includes information on upcoming events, private lesson deals, and upcoming MMPA enrichment sessions. You can opt out at any time.

I, the undersigned parent/guardian of the registrant, acknowledge the possibility that participation in Mode Music and Performing Arts activities could result in physical injury to the registrant. I hereby release, discharge and agree to hold harmless Mode Music and Performing Arts, its officers, directors, employees, agents and affiliates from any and all claims arising from or related to the registrant’s participation in Mode Music and Performing Arts activities. 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. *