2022-23 Alameda Music Project - Maya Lin Enrollment Application

1st PARENT/GUARDIAN INFORMATION
Parent/Guardian 1 Name *

First Name Last Name
Cell *

Area Code Phone Number
Home

Area Code Phone Number
Work

Area Code Phone Number
E-mail *
Address - Same As Child

Yes No
Parent/Guardian 1 Address

Street Address

Street Address Line 2

City State

Zip Code
Enter 2nd Parent/Guardian Information?

Yes No
2nd PARENT/GUARDIAN INFORMATION
Parent/Guardian 2 Name

First Name Last Name
Cell

Area Code Phone Number
Home

Area Code Phone Number
Work

Area Code Phone Number
Parent/Guardian 2 E-mail
Address - Same As Child

Yes No
Parent/Guardian 2 Address

Street Address

Street Address Line 2

City State

Zip Code

EMERGENCY CONTACT - OTHER THAN PARENT/GUARDIAN
Full Name *

First Name Last Name
Relationship to student *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Cell *

Area Code Phone Number
Home

Area Code Phone Number
Work

Area Code Phone Number
PICK UP POLICY

To avoid late pick up fees, please list any additional people who may pick up your student(s) from Alameda Music Project. Children will not be released to individuals not listed on this form. If you would like to add more people after submission, please email their contact information to audrey@bayareamusicproject.org.
My child will be picked up by an authorized adult (age 18+) *

Yes No
Please list the people authorized to pick up your child.
I authorize my child (9 years or older) to sign themselves out and walk home after program. *

Yes No
Initials *
Is there anyone restricted from picking up your child?

BEHAVIOR AGREEMENT
A behavior agreement for students and parents/guardians is included in the AMP Family Handbook distributed at the beginning of the year and must be read and signed by October 1st in order to continue participating in the program. The Alameda Music Project staff reserves the right to deny service to anyone. In the event of inappropriate conduct by a student or parent/guardian, significant lateness and/or absences, staff will make a determination regarding program participation.
PROGRAM EVALUATION CONSENT
Program Evaluation Consent
I authorize my child to participate in program evaluation activities. These may include interviews, journaling, assessments, tasks, or other evaluative tools. Alameda Music Project will keep this information confidential, only presenting such information to the public with identifying information removed or in aggregate form (group averages). I am also aware that Alameda Music Project will be contacting parents/guardians to assist in the program evaluation process, and that I will be asked to participate in this process. This may include filling out surveys or assessments and participating in interviews.
Program Evaluation Consent *

Yes No
Publicity Release Agreement & Consent for Participation/Liability Release
As a parent of an Alameda Music Project (AMP) participant, I understand that publicity and donations in support of the organization can be earned through performing. Students are expected to participate with AMP in scheduled performances.

I consent to AMP receiving all payments for student performances involving my minor child/ward which may include but are not limited to: concerts, commercials, films, radio, community/civic events, billboards, internet presence, flyers, and newspaper and television appearances. I give consent for my child/ward’s image, voice and artwork to be used in association with publicity, fundraising and community activities, exclusively on behalf of AMP.

Please be advised AMP takes photographs and video and/or audio recordings of rehearsals, productions, concerts and other activities. Their uses include, but are not limited to print, web, video sharing sites such as Youtube and Vimeo, the news media and independent production companies. The likeness of any person involved with AMP could possibly appear in these recordings. AMP has the irrevocable right to film, record, and reproduce materials for broadcast and commerce, which may contain your child’s likeness. I understand that AMP practices full disclosure of program revenue sources and I may request such information at any time.
Publicity Release Agreement *

Yes No
Initials *
Hold Harmless Agreement
By registering your minor child/ward for participation in Alameda Music Project you will be waiving your rights and/or the rights of your child/ward to all claims for injuries your minor child/ward might sustain arising out of this program and you will be required to indemnify, hold harmless and defend the Alameda Music Project and Bay Area Music Project for any claims arising out of participation in said program.

Risk of Injury: As a participant in the program, or as a parent or legal guardian of a participant under 18 years of age, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of injuries, including death, damages, or loss which I may sustain as a result of participating in any and all activities associated with this program.

Indemnify and Defense: I further agree to indemnify, hold harmless and defend the Alameda Music Project and Bay Area Music Project and its officers, agents and employees from any and all claims from injuries, including death, damages and losses sustained by me or my minor child/ward and arising out of, connected with, or in any way associated with the activities of the program.

Release from Liability: I do hereby fully release and discharge Alameda Music Project and Bay Area Music Project and its officers, agents and employees from any and all claims from injuries, including death, damage or loss which may occur on account of participation in the program.

Waiver of Injury Claims: I agree to waive and relinquish any and all claims I may have arising out of, connected with, or in any way associated with the activities of the program.” In the event of any emergency, I authorize Alameda Music Project to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed reasonable and necessary for me or my minor child’s immediate care and agree that I will be responsible for payment of any and all medical services rendered.
Initials *
COVID 19 Pandemic Authorization & Waiver
I, the undersigned, understand the in-person nature of the Alameda Music Project (AMP) after-school program and that participation is voluntary.

The risks of injury and illness (ex: communicable diseases such as MRSA, influenza, and COVID-19) to my child from the activities involved in this program is significant, including the potential for permanent disability and death. While particular rules, equipment, and personal discipline may reduce this, the risks of serious injury and illness do exist; and, I further understand that accidents and injuries can arise out of program events and activities. Knowing the risks, nevertheless, I hereby agree to assume all risks of damage, illness, injury, or loss to person or property that is sustained while participating in, attending, traveling to and from the Alameda Music Project after-school program.

My child will not attend school and the AMP if they or the person transporting them show any symptoms of illness including, but not limited to:
- A temperature over 100 degrees Fahrenheit
- Cough
- Shortness of breath or difficulty breathing
- Chills and/or repeated shaking with chills
- Muscle Pain
- Headache
- Sore Throat
- Loss of taste or smell
Signature *

Clear
Should be Empty:

2022-23 ALAMEDA MUSIC PROJECT ENROLLMENT APPLICATION

PROGRAM FEES AND HOURS

FINANCIAL ASSISTANCE

ENROLLING STUDENT INFORMATION

ENROLLING STUDENT INFORMATION

ENROLLING STUDENT INFORMATION

The following is statistical data we collect to report to our funders. This information, while very helpful to AMP, is not used to make decisions about your child’s participation. Please select the ethnicity that best describes the student (check all that apply).

OTHER INFORMATION

1st PARENT/GUARDIAN INFORMATION

2nd PARENT/GUARDIAN INFORMATION

MEDICAL INFORMATION

EMERGENCY CONTACT - OTHER THAN PARENT/GUARDIAN

PICK UP POLICY

BEHAVIOR AGREEMENT

PROGRAM EVALUATION CONSENT

Publicity Release Agreement & Consent for Participation/Liability Release

COVID 19 Pandemic Authorization & Waiver