Student Name * First Name Last Name Student Date of Birth MM DD YYYY Parent Guardian Email * Parent / Guardian Name * Registering for: Wednesdays at 4:00 pm Thursdays at 4:30pm Parent / Guardian Phone (###) ### #### Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Favorite Music * How did you hear about MCMA * Emergency Contact Name (Other than parent / guardian for minor) * First Name Last Name Relationship to Student * Emergency Contact Phone (###) ### #### Relevant Medical Information (includes allergies, conditions, medications, etc) Student Policy Agreement and Waiver Release (must accompany Registration Form) I am, an adult or the parent/legal guardian of the student, willingly enrolling in classes, lessons, and/or other related activities with Midcoast Music Academy. I have read the MCMA Policies and I clearly understand and agree to the MCMA payment and cancellation procedures within. By signing below, I acknowledge that I understand and agree to all policies, guidelines and conditions set forth above. Participation: I hereby consent and agree, for myself/my minor child, to participate in classes, lessons, rehearsals, performances and/or other related activities with Midcoast Music Academy (MCMA). I understand that I am fully responsible for myself/my child until such time that my/my child’s class, lesson, or other MCMA activity begins, and that I also am responsible for myself and/or my child immediately upon the conclusion of my/his/her activity at MCMA. This includes, but is not limited to, transportation to and from MCMA, all time spent waiting for the scheduled lesson to begin, and/or waiting for pick-up following a lesson. In consideration for MCMA accepting me/my child into its program, I do hereby for myself, my spouse, my children, our heirs, personal representatives and assigns, expressly release and forever discharge MCMA, its officers, agents, and employees of and from any liability and all claims, suits, or causes of action arising from or as a result of my/my child’s participation in MCMA programs, including, without limitation, injuries or damages sustained by myself and/or child on property managed by MCMA. Emergency: In the event of an emergency, I hereby authorize and request MCMA to provide or secure me/my child to receive emergency treatment at a hospital and/or from a licensed physician should the need arise. I hereby give my consent for MCMA to seek necessary emergency medical treatment for me/my child, and for me/my child to receive such emergency medical treatment, which may be deemed necessary or advisable in the event of injury, accident or illness. I further understand that the emergency contact listed will be called immediately if any emergency arises and I accept financial responsibility for all such medical treatment that may be provided. I have read the above and consent to the MCMA Student Policy Agreement and Waiver Release. I give permission to receive SMS alerts sent to my cell phone from My Music Staff (MMS). MCMA may use student photos, video footage, and quotes in print and electronic publications, on social media, and in media coverage of MCMA. I understand MCMA will only use first names when sharing student media publicly. Permission Given Permission Refused Electronic Signature First Name Last Name Date MM DD YYYY Thank you!
