Brain Beats

Summer Camp Registration

Please fill this form out for EACH CHILD
Child's Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Does the child have an educational diagnosis? If yes, would you mind sharing your child's diagnosis? Also, please explain how the educational diagnosis might affect the child's learning needs or behavior. (This helps our teaching be more effective for your child's success). *
Is there anything else you wish us to know about your child?
Camp Selection

What camp are you signing your child up for?
Appointment*
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Music on Main during the selected camp. In exchange for the acceptance of said child’s candidacy by Music on Main, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Music on Main and all its respective teachers 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 Music on Main including all teachers and assistants, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the {Organization} . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
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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Payment

We will not hold your spot until you have paid! Please venmo sarahhines2 or you can write a check to Music on Main and mail it to 103 East Main Street, Danville, KY 40422! Thank you!
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Summer Camp Registration

Child's Information

Camp Selection

Payment