Adult Camper / Staff Registration Form 2024

ADULT CAMPER & STAFF REGISTRATION
Walker Creek Ranch, Petaluma, CA Nov. 22-24, 2024
Registration Fee: Waived
Mission Statement:Mountain Harmony Camp is dedicated to forming a safe and supportiveenvironment for every girl to freely explore her voice and expand her creativity while discovering the joy of a cappella singing through high quality education in Barbershop style harmony.
Name
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver Lic #
Contact#s
Cell phone
Home / Work phone
Email
example@example.com
FOR SWEET ADELINES ONLY If you are applying as a Staff member you must be a current dues paying member of International and Region 12. Please check all memberships that apply to you;

Region 12 memberChapter at Large memberRegistered Quartet member - List quartet name belowChorus member - List Chorus Name below
Quartet Name
Education / Experience
List any Education & Experience qualifying you to work with teens / young singers;
Employer
If retired or unemployed - check box and list last employer below

RetiredUnemployed
Company Name
Job Title
Address
City, State, Zip
Phone
Dates employed

MonthDayYear
Date
List your duties
Reference #1

PLEASE LIST ONE PERSONAL REFERENCE WE MAY CONTACT
Name
Relationship to you
Address

Address

Street Address Line 2

City,State,ZipState / Province

Postal / Zip Code
How long have they known you?
Cell phone
Home phone
Work phone
Reference #2
Please list one PROFESSIONAL reference we may contact; (not a relative)
Name
Relationship to you
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Cell phone
How long have they known you?
Home phone
Work phone
Special Meals
Please check any special meal requirements you may have

Gluten FreeVegetarianVeganOther
Complementary T-Shirt
Check your cotton T-shirt size

Child XLgSm AdultMed AdultLg AdultXLg Adult1X2X3X
Emergency Contact / Medical Information
Contact Name
Relationship
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone #1
Phone #2
You may list any medical/prescription drug information a first responder would need to know about you. Information will be kept confidential.
Release of Claims
I acknowledge that I am participating in Sweet Adeline International’s, Region 12, Young Women in Harmony Program’s, Mountain Harmony Camp, further known as (the Event), Nov. 22-24,2024, at Walker Creek Ranch, Petaluma, CA, on my own accord. I give this acknowledgement freely, and knowingly, and I represent and warrant to you that I am physically and mentally fit, and that as a result, am able to participate, and I do hereby assume responsibility for my own well-being. I am fully aware that possible physical injury might occur to me as a result of my participation, and I agree to assume the full risk, including risk which is not specifically foreseeable, of any injuries, including death, damages, or loss, regardless of severity, which I may sustain as a result of participating in any and all activities connected with or associated with the Event. In consideration of the right to participate in the Event, I hereby waive any and all rights or claims I may have as a result of participation in the Event against Sweet Adelines International and further agree to indemnify, defend, and hold harmless Sweet Adelines International, its directors, officers, employees, members, staff, and all individuals assisting in instructing and conducting these activities, and I hereby fully release and discharge them from any and all claims resulting from injuries, including death, damages, or loss, which may accrue to me or my heirs, arising out of, or in any way connected with my participation in the Event.

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Release of Claims - Print Name
Release of Claims - Date Signed

MonthDayYear
Date
Photo/Recording Release
I hereby give permission for Sweet Adelines International and any of its affiliated organizations, including, but not limited to its regions and chapters, to use my name and/or photographs/artwork/videotapes/electronic representations and/or sound recordings on an ongoing basis for promotional, news, or public relations purposes in print and/or electronic media. I hereby consent that such photographs/artwork/videotapes/electronic representations and/or sound recordings shall be the property of Sweet Adelines International and any of its affiliated organizations. They shall have the right to duplicate, reproduce, and make other uses of such as they desire, free and clear of any claim whatsoever on my part. All rights to fees, commissions, royalties, or profits received as the results of the distribution, sale, or lease of the recordings in any form, are assigned to Sweet Adelines International, to be used in any manner consistent with the purpose of Sweet Adelines International.

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Photo/Recording Release - Print Name
Photo/Recording Release Date Signed

MonthDayYear
Date
For questions call Cyndi Sharp: 925-639-2963
Should be Empty:

ADULT CAMPER & STAFF REGISTRATION

Registration Fee: Waived

Contact#s

Education / Experience

Employer

Reference #1

Reference #2

Special Meals

Complementary T-Shirt

Emergency Contact / Medical Information

Release of Claims

Photo/Recording Release