Fine Arts 2023

Optional Praise and Worship Workshop at 8:30 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

Due to financial restraints, we regret to say that we will not be serving a full breakfast this year. However, we will have some breakfast snacks available.
Food Allergies/ Special Dietary Restrictions*
Please upload a picture of your child with allergies for extra precautions during camp. We would also love to introduce your student to the cooks on the first day.

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Medical and Liability Release
Transportation
Fayette County Schools is working to get buses for the Fine Arts camps. We will confirm transportation availability as soon as possible.*

If available, I WOULD like busing for my childMy child will NOT be riding the bus
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.
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 Information
Emergency Contact (This is who we contact when we cannot reach Parent/Guardian 1 or Parent/Guardian 2)*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to student*
Allergies*
Food, Insects, and/or Drug
Any Medical Problems and Medications that we should be aware of*
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, Jessica Moneypenny, Eric Snuffer, 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 the camp director or associated adult supervisor as permitted by The Health Insurance Portability and Accountability Act of 1996 (HIPAA). I also understand that although the students will be supervised by Coda Mountain Academy staff, I do assume the risk in my student’s participation in the event and transportation to and from the event if applicable. I acknowledge that I will not seek to have Coda Mountain Academy held liable in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of my son’s/daughter’s participation in the field trip.This release of liability includes accident, injury, loss, or damages to the student, as well as, to other individuals or property which may result from the student’s participation in the event. I hereby release and agree to hold harmless Coda Mountain Academy, its officials, agents and employees, from any claims arising out of my son’s/daughter’s participation in this event.*

I have read and understand and accept all of the statements recited above and accept full responsibility as described.
Signature*

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Date

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Date

Questions or Comments?
How did you hear about us? (select all that apply)*

A friendNewspaper, TV or RadioPaper FlierCoda Inspire studentRail Trail ExpoOther

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

CODA FINE ARTS

Classes (9:00am - 4:00pm)

Instrument Loan Policy

Medical and Liability Release

Transportation

Photo Waiver

Medical Information