MMPA 2020 SUMMER CAMP REGISTRATION

STUDENT INFORMATION

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PRIMARY CONTACT INFORMATION

Relationship To Student *
 

SECONDARY CONTACT INFORMATION

Relationship To Student *
 
I agree that I am responsible for paying the full amount of the camp tuition upon registration. Partial payments may result in loss of deposit or spot in the 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

HEALTH INFORMATION

BEHAVIORAL INFORMATION

MEDICATION 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 (leave blank if none):
 NameDose / FrequencyDuring Class / CampSelf Admin / Teacher Assistance
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2.
3.
4.

ALLERGY INFORMATION

AM CAMP SELECTION ROCK BAND OR DANCE/THEATRE

MORNING CAMP OPTIONS

CHOOSE ONE OR MORE WEEKS OF 9:00AM - 12:00PM ROCK BAND CAMPS @ $350 (with a Saturday 5pm performance at the Skylark) *
OR CHOOSE ONE OR MORE WEEKS OF A 9:00AM - 12:00PM THEATRE OR DANCE CAMPS @ $225 (demonstration at 11:45AM on Friday) *

PM CAMP SELECTION DANCE/THEATRE

AFTERNOON CAMP OPTIONS

CHOOSE ONE OR MORE WEEKS OF 12:30PM-3:30PM THEATRE OR DANCE CAMPS @ $225 *OR* @ $150 if paired with an AM camp (demonstration at 3:15PM on Friday) *

AFTER CARE AM AND PM

BEFORE AND AFTER CAMP CARE

BEFORE AND AFTER CARE 8AM-9AM & 3:30PM-5:30PM *

BEFORE CAMP CARE

BEFORE CARE *ONLY* 8AM-9AM *

AFTER CAMP CARE

AFTER CARE *ONLY* 3:30PM-5:30PM *

PAYMENT

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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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