Summer Camp Detailed Registration Form

Summer Camp Registration
Student Information

Please fill out 1 form per student.
Student’s Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Gender

MaleFemale
Are you a MusIQ™ member?*

YesNo

Please select the camp(s) your student will be participating in.*

iWrite Camp$400 for non-members and $350 for MusIQ™ members. $200 for 1 month. *non refundable $50 deposit

$50.00 iWrite package

Music Explorers$400 for non-members and $350 for MusIQ™ members. $200 for 1/2 camp 9pick 2 instruments). *non refundable $50 deposit

$50.00 Music Explorers Package

Introduction to Woodwinds$300 for non-members and $250 for MusIQ™ members. *non refundable $50 deposit

$50.00 Instrument

Introduction to Brass$300 for non-members and $250 for MusIQ™ members. *non refundable $50 deposit

$50.00 Instrument

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Minds On Music during the selected camp. In exchange for the acceptance of said child’s candidacy by Minds On Music. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Minds On Music. 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 Monds On Music. including all teachers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
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.
Date*

MonthDayYear
Date
Signature*

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Summer Camp Registration

Student Information