Urban Summer Series Registration Form

Child's Name

First NameLast Name

Age

Parent/Guardians Name

First NameLast Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Emergency contact & Relationship to the Child.

Contact Name

First NameLast Name

Relationship To Child

Phone Number

Area CodePhone Number

Contact Name

First NameLast Name

Relationship To Child

Phone Number

Area CodePhone Number

Password if someone else is picking up the child.

Please give brief detail

Does your child have severe allergies/anaphylaxis. If your child requires an epi-pen, please make sure you are in the building.

Please give brief detail

Does your child have Asthma? If Yes, please advise administrator & ensure they bring their inhaler

Is your child taking any medication, if Yes please give details

Please give detail

Please complete the following to the best of your knowledge and discuss any specific concerns you have with me and together we can support your child.

	Very	kinda	Not so much
How interested is your child in songwriting?
How supportive are you of your child creating music?
How confident is your child about their music?
How confident is your child about performing their music?
How well does your child take constructive criticism?

How did you hear about our Urban Summer Series

Urban Summer Series include identity development, self expression songwriting, sound recording and performance. Do you consent to your child being involved.

Signature

I individually as a parent/guardian of the child identified above hereby agree to the following:

I confirm that I have fully disclosed to Urban Summer Series and/or the Coach any and all conditions (whether physical, mental or behavioral or otherwise) that my child has or may have before my child participates in the class.

As far as is permitted under Local Law, I assume the above risks and accept responsibility for any injury sustained by my child. I further discharge and hold harmless Urban Summer Series including its owners, officers & personnel including its coaches and its suppliers from any liability arising from any injury to my child or other persons or property caused by my child’s participation in the Urban Summer Series program if that injury is caused either by my or my child’s fault; or by a third party unconnected with Urban Summer Series. The provision of services; or by events with Urban Summer Series, its owners, officers & personnel including its coaches and supplier, could not have foreseen or prevented even if they had taken reasonable care.

Refunds: Refunds will be given if cancellation is made in writing before the first attended class of the series. I understand and agree that I will not receive any refund or credit for missed classes.

Urban Summer Series takes all reasonable care to ensure that its program is fun and safe. In the event of an emergency 911, as well as the parent/guardian will be contacted ASAP.

DateTime

Registration Fee*

USD$50