Fine Arts 2022

Optional Praise and Worship Workshop at 8:00 a.m.

Yes, I would like my child to attend this workshop which includes Christian praise and worship music. No, my child will not be attending

Terms
Liability Waiver: I acknowledge that the overall health and well being of my child/children is my responsibility. I am aware that my child will be exposed to others including but not limited to Coda staff, students, interns, teachers and volunteers. In the chance that my child is exposed to COVID-19 or any other contagious disease, there is a risk of illness, permanent disability, and even death. In the event that any issue listed above were to occur, I agree to not sue nor seek any legal action, neither would Coda Mountain Academy, supervisors, staff, volunteers, interns, nor teachers will be held accountable. *

I understand and acknowledge the liability waiver written above and that Coda Mountain Academy nor any supervisor, staff, volunteer, intern nor teacher will be held accountable for the risk of exposure to COVID-19 or any other liabilities.
Signature *

Clear
Transportation

We do have busing for surrounding areas.
Bus Policy: If you selected "My child will be riding home on the bus" a signed note from the parent/guardian must be provided each time they will NOT be riding the bus home. BUS STUDENTS MAY NOT WALK OR CAR RIDE WITHOUT WRITTEN PERMISSION FROM PARENT/GUARDIAN. *

My child WILL be riding the bus My child will NOT be riding the bus
Photo Waiver

Understanding that Coda photos and videos are important to promote public awareness, access future scholarship funding and reach more youth, I hereby consent for my child (or myself if 18 or older) to be photographed and/or videoed for Coda Mountain Academy. The resulting photographs or videos may be subsequently used without compensation to me by Coda Mountain Academy, or third parties for publications (including web sites,) advertising, and/or publicity purposes at the discretion of Coda Mountain Academy. Some photos and videos will be used in the year end grant report. I waive the right to inspect or approve the finished photograph, video and/or publication use.
I, parent or guardian, consent to the above photo/video waiver for Coda. I, parent or guardian, do NOT consent to the above photo/video waiver for Coda.
Medical Release
Emergency Contact (This is who we contact when we cannot reach Parent/Guardian 1 or Parent/Guardian 2) *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to student *
Release

I, the undersigned, am the parent or legal guardian of this minor and have given my consent for him/her to participate in activities hosted by Coda Mountain Academy. In the event of injury, accident, illness or other emergency while participating in the camp, I consent to any reasonable medical treatment as deemed necessary by a licensed physician, emergency medical technicians, nurses, and laboratory technicians. In the event any treatment is required, which a physician and/or hospital personnel refuses to administer without my consent, I hereby authorize Esther Morey, Robert Morey, Kathie Kiser, or an associated adult supervisor to give such consent for me, if I cannot be reached by telephone at one of the numbers listed above, or because of an emergency in which there is no time or opportunity to make a telephone call. In the event it becomes necessary for that person to give consent for me, I agree to hold such person, other associated adults and Coda Mountain Academy free and harmless of claims, demands, or suits for damages which may arise from the giving of such consent. I also acknowledge that I accept to be ultimately responsible for the cost of any medical care whether or not the cost of that medical care will be reimbursed by my health insurance provider. Further, I affirm that the health insurance information provided in the medical release form is accurate as of this date. I further authorize disclosure of medical information by a treating physician to Esther Morey, Robert Morey, Kathie Kiser, or associated adult supervisor as permitted by The Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Today's date *
Allergies
Food, Insects, and/or Drug
Any Medical Problems and Medications that we should be aware of
*

I have verified the above details are correct and that I have read this release and agree with the content.
Signature *

Clear

The link to the scholarship application will be on the confirmation page after this registration form is submitted.
Questions or Comments?
How did you hear about us? (select all that apply) *

A friend Newspaper, TV or Radio Paper Flier Coda Inspire student Rail Trail Expo Other

Payment Options

Pay tuition NOW ($175) Pay first day of camp ($175) I need help and would like to apply for a scholarship.
My Products
prev next ( X )
Tuition $ 175.00

Pay with PayPal

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Coda Fine Arts Day Camp

Classes (8:30am - 4:00pm)

Instrument Loan Policy

Terms

Transportation

Photo Waiver

Medical Release

Release