Music Warehouse Boot Camp
Request to Participate
Name: (Last, First)______
Address:______
City, State, Zip: ______
Day Phone #______Evening Phone #______
Parent/Guardian
Cell Phone #______Email: ______
Parent/Guardian:______
Date of Birth:______Gender: (circle one) M F
Grade entering This Fall :______Your School This Fall:______
T-Shirt Information (circle one):Shirts 100% Cotton
Youth size S M L Adult size S M L XL XXL
Cost to Participate: $10.00 This must be included with these request formsand returned by Saturday, May 12, 2018.
**Parent Opportunity to Volunteer: Please Circle your preference.
M T W Th F 9:00 am – Noon
Name:______
Mail forms and money to Music Warehouse, 1327 Maplewood Drive, Piqua, OH 45356Checks need to be made out to Music Warehouse
Music Warehouse
Parent Authorization Form
Release Form on Back
Participant Information
Name______
Parent Information
Name ofother/Father/Guardian______
Home Address______Phone______
City, State, Zip______
In case of illness or emergency, Music Warehouse will attempt to contact the parent/guardian first. If parent/guardian cannot be contacted, please list two contact people to whom we may release your child.
Others to be contacted in order listed:
Name______Relationship______
Home Telephone______Cell Phone______
Name______Relationship______
Home Telephone______Cell Phone______
Medical Information
Family Doctor______Telephone______
Preferred Hospital______
Allergies______
PLEASE COMPLETE PART I OR PART II, NOT BOTH SECTIONS
The purpose of this form is to enable parents or guardians to authorize or refuse the provision of emergency treatment for children who become ill or are injured while under Music Warehouse authority when parents or guardians cannot be reached.
Part I To Grant Consent:
In the event reasonable attempts to contact my designee or me have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by family physician or dentist. In the event the designated practitioner is not available, authorization is granted for treatment by another licensed physician or dentist. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery are obtained prior to the performance of such surgery.
______
Signature of Parent/GuardianDate
Part II Refusal to Consent:
I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the staff to take no action.
______
Signature of Parent/GuardianDate
Release
Recognizing the possibility of physical injury associated with dancing and otherwise performing upon a musical production stage and/or raised platform erected upon such stage, and for Music Warehouse's accepting the Performer for its practices, performances and other activities, I hereby release, discharge and/or otherwise indemnify Music Warehouse, its affiliated organizations, sponsors, members, Trustees, Directors, Officers, committee members, agents and employees, for and against any claim by or on behalf of the Performer as a result of the Performer's participation in Music Warehouse.
As a Music Warehouse participant, I hereby release the use of photographs, video, and audio for publicity and/or public use of my child or me.
______
Performer's signature (if at least 18 years of age)
______
Print Performer's name
______
Parent/Guardian's signature (if Performer is under 18 years of age.)
______
Print Performer's name
_______
Print Signer's name