CommonChord Summer Songwriting Intensive 2019 Registration Form

CommonChord Summer Songwriting Intensive Registration Forms

TO BE FILLED OUT BY PARENT/GUARDIAN
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
Date
Parent Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Email Address
example@example.com
Parent Daytime Phone Number

Area CodePhone Number
Parent Cellphone Number (if different)

Area CodePhone Number
Which mode of communication (non-emergency) do you prefer?

TextEmailPhone Call
Student Email
example@example.com
Student Cellphone

Area CodePhone Number
Student Gender
Emergency Contact

First NameLast Name
Emergency Daytime Phone

Area CodePhone Number
Emergency Contact Cellphone (if different than above)

Area CodePhone Number
Parent/Student Agreement Form
CommonChord Project students are afforded fantastic opportunities to learn, create, grow, discover and build new friendships. With these opportunities and freedoms come responsibilities. Throughout the program, each student will be expected to conduct him/herself as a mature, law-abiding, cooperative and responsible individual. We insist on an atmosphere of respect, trust and consideration in the students’ dealings with fellow students and program leaders. We are creating together and this means we also are collectvely responsible to create a safe community.

While do not forsee any problems in our small group, there are the clear guidelines expected in the program. These are the expectations:

Participation: CommonChord students are required to attend all group sessions.

Respect: Students are expected to respect the individual rights of all members of the CommonChord community and treat each other with courtesy.

We are guests Newport Street Retreat. We ask that students respect the space and keep it well-kept during their stay and clean up after themselves.

Alcohol/Drugs: CommonChord Project has a zero-tolerance policy for involvement with alcohol or illegal drugs. We will have sole and complete discretion in identifying and determining involvement in incidents relating to drugs and alcohol.

Personal Safety: Students may not leave defined CCP areas without a staff member.

Interpersonal Relationships: CCP respects and supports the development of friendships amongst students. Students are advised, however, that
appropriate behavior and conduct is expected at all times.

Internet Use: Students are responsible for appropriate behavior on host networks. There will be periods of time during the group sessions when we ask that cellphones are put away and need this to be respected.

Housing: We are staying at the Newport Street Retreat. Students are expected to respect the privacy of their peers and are not allowed to visit in areas of friends of the opposite gender(s) after designated times.

Curfew: CCP will have clearly defined curfews.

Smoking: Smoking is prohibited at Newport Street Retreat.
PARENT/GUARDIAN:
I have read through the CommonChord Project website and forms and hereby give permission for my child/ward to participate in the CommonChord Summer Songwriting Intensive during the summer of 2019. My child/ward is enthusiastic and prepared, and I believe he/she is capable of handling the emotional, intellectual and physical aspects of the program as well as any risks involved. I understand and agree to the above terms and policies and consent for my child/ward to participate in the CommonChord program during the summer of 2019.
Parent/Guardian:

First NameLast Name
Signature

Clear
STUDENT PARTICIPANT:
I acknowledge that I have read and understand CommonChord Project's Parent/Student Agreement above. I understand expected behavioral guidelines and that CommonChord Project or its agents have the right to dismiss me and return me home at my and my parent/guardian’s expense without refund of the program fee, should I be found in violation of these rules.
Student:

First NameLast Name
Signature

Clear
Medical Documentation/Permission to Treat

REQUIRED FORM - To be completed by Parent/Guardian. No Physical Exam Required
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Parent/Guardian 1

First NameLast Name
Home Telephone

Area CodePhone Number
Cellphone

Area CodePhone Number
Parent/Guardian 2

First NameLast Name
Home Telephone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Emergency Contact

First NameLast Name
Cellphone

Area CodePhone Number
Primary Physician

First NameLast Name
Physician Telephone

Area CodePhone Number
Insurance Company
Insurance Holder
Policy Number
Are there any dietary restrictions?
Are there any health concerns we need to be aware of? (Vision, Speech, Hearing, Allergies, Psychological or Physical Disorder, Diabetes, Seizures etc.):
NON-PRESCRIPTION MEDICATIONS: Please check all non-prescription medications that you will allow CCP to administer to your child if needed:

Acetaminophen (i.e. Tylenol)Ibuprofen (i.e Advil)Pepto-BismolImmodium ADBenadryl / allergiesDayQuil / cough & coldOther
PRESCRIPTION MEDICATIONS: (if applicable): Please list dosage; method/time of administration; and may student self-administer? All medication must be in original container, labeled with child’s name.
The above information, pertaining to the above student, is a complete record of his/her prescription/non-prescription active history. I request that medication be administered to or by my child as described and directed above.
Signature

Clear
I have read and understand the statements in this release form. I understand that should a health problem arise, I will be notified but if I cannot be reached by telephone I consent to emergency medical treatment, which may include surgery for my child as deemed necessary by competent medical personnel. I also consent to the release of information for insurance purposes.
Signature

Clear
Photography and Media Release Form
I grant permission to CommonChord Project, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child while at CommonChord Summer Songwriting Institute for any lawful purpose including publication, promotion, advertising, education or historical archive in any manner or in any medium.

I hereby release CommonChord Project and its legal representatives from liability for any violation or claims relating to said images or video. Furthermore, I grant permission to use the statements of my child, given during an interview or evaluation with or without their name for the purpose of publicity and education purposes without restriction to time limit or geographic area.

I waive my right, my child’s rights, to any and all compensation stemming from the use of these materials.
Parent/Guardian

First NameLast Name
Signature

Clear
Payment

Payment in full is due: June 30, 2019
How are you making payment?

Credit Card Payment (preferred)Check made out to: Jan Nadav, CommonChord Project, 1181 Newport Street, Denver, CO 80220
My Products
prevnext( X )
CommonChord Summer Songwriting Intensive$400.00

Total $0.00
loading smart payment buttons...

The payment is ready! It will be completed once you submit the form.
CommonChord Project is actively seeking donations through our fiscal sponsor, Nautilus Music-Theater - to cover costs and offer scholarships. Should you want to make an additional tax-deductible donation please go to:

Donation
Should be Empty:

CommonChord Summer Songwriting Intensive Registration Forms

Parent/Student Agreement Form

Medical Documentation/Permission to Treat

Photography and Media Release Form

Payment