Summer Camp Detailed Registration Form

Camper Information

Camper #1

First Name Last Name

Gender

Male Female N/A

Age Of Camper:

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Which camp or camps are you signing up for?

June 6th-10th, 2022 August 1st-5th, 2022

Do you play a musical instrument? If "yes," list your main instrument here: *

If you play an instrument, what would you say your skill level is?

Beginner Intermediate Advanced Wicked Awesome, Bro

Parent/Guardian Information

Name *

First Name Last Name

Home Number

Area Code Phone Number

Cell Number *

Area Code Phone Number

E-mail *

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship

Phone Number *

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

Will the camper need to take prescribed medication while at camp? If yes, please explain any instructions.

If your camper has any special needs that we can accommodate, please list them here:

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Central Iowa Music Lab during the selected camp. In exchange for the acceptance of said child’s candidacy by CIML, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless CIML and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against CIML including all counselors, directors, affiliates, participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to CIML and its affiliates including Directors, Counselors, and Assistants to provide the needed emergency treatment prior to the child’s admission to the medical facility.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Media Release Form

I, the undersigned, do hereby grant permission to Central Iowa Music Lab to post my and/or my child’s story, photo, or other item, hereinafter referred to as “Materials,” I submit to and for Central Iowa Music Lab's Web site, Twitter & Instagram accounts (@DSMMusicLessons), and Facebook account.

I hereby release you, your representative, employees, managers, members, officers, parent companies, subsidiaries, and directors, from all claims and demands arising out of or in connection with any use of said “Materials”, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation and any other personal and/or property rights.

I acknowledge and agree that no sums whatsoever will be due to me as a result of the use and/or exploitation of the “Materials” or any rights therein.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature Of Parent Or Guardian *

Clear

Camp Tuition: *

Camp Deposit $ 100.00

This amount is to hold your student's spot for their chosen camp. Deposit amount is per camper. This amount is non-refundable and will be deducted from the total camp cost. *Remainder of camp tuition must be paid NO LATER than June 1st, 2022 or the deposit will be forfeited*

Quantity

Full Tuition-EARLY BIRD RATE $ 300.00

Registration for one or more summer camps received on or before April 30th, 2022.

Quantity

Full Tuition-STANDARD RATE $ 325.00

Registration for one or more summer camps received between May 1st and June 5th, 2022.

Quantity

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

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Rock 'N' Play Camp Registration