Roseville Summer Music Camp Registration
Email address *
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name *
(first) (last)
Your answer
Parent/Guardian Address *
(street) (city) (state) (zip)
Your answer
Parent/Guardian Home Phone Number *
Your answer
Parent/Guardian Work or Cell Phone Number *
Your answer
Parent/Guardian Email *
Your answer
EMERGENCY CONTACT INFORMATION
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Relationship to Student *
Your answer
INSURANCE INFORMATION
Family Physician *
Your answer
Physican Phone Number *
Your answer
Insurance Carrier *
Your answer
Insurance Policy Number *
Your answer
Please list any medications taken, allergies, and any other necessary medical information.
Your answer
STUDENT INFORMATION
Student Name *
Your answer
Student Grade *
(grade student will have finished at the end of the 2018/19 school year)
Your answer
School Student Attends *
Your answer
Student's Primary Instrument *
Your answer
Student's Secondary Instrument
Your answer
Session Attending *
Required
SESSION 1 (June 10 - 14) - Primary Ensemble
SESSION 2 (June 24 - 28) - Primary Ensemble
T-Shirt Size *
(T-shirts are only guaranteed if registered by June 1, 2019)
PARENTAL CONSENT, RELEASE FROM LIABILITY AND INDEMNITY AGREEMENT
This is a legal document which, if signed, will have the effect of rendering you and your child unable to bring any type of action against the Roseville Middle School Music Camp, the Roseville Community Concert Band or any of their agents, because of any harm you or your minor child may suffer as a result of his/her participation in a voluntary program of the Roseville Community Concert Band.

REQUIRED FOR PARTICIPATION
This is a legally binding release made by the parent/guardian for the student who I/we have voluntarily registered; I/we do hereby consent to his/her participation in the Roseville Middle School Music Camp (hereinafter referred to as “Camp”) sponsored by the Roseville Community Concert Band (RCCB).

I/we hereby forever RELEASE, discharge, and covenant to hold harmless the Camp, the Roseville Community Concert Band, and the officials, committees, officers, agents, employees, insurers, attorneys, servants, affiliates, and their successors and assigns of each of the named entities, from any and all manner of actions and causes of action, agreements, judgments, settlements, damages, claims, and demands whatsoever, known or unknown, at law or in equity, on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which I/we may now or hereafter have as then parent and/or adult participant, and also all manner of actions and causes of action, agreements, judgments, settlements, damages, claims, and demands whatsoever, known or unknown, at law or in equity, which participant has or hereafter may acquire, either before or after he/she has reached his/her majority, resulting from his/her participation in any voluntary programs of the Camp and the Roseville Community Concert Band. I/we understand that the Camp reserves the right to dismiss a child due to that child’s disruption of the program. A child’s dismissal will be at the discretion of the Camp Directors. I/we grant permission for my child to participate in all activities that are part of the Camp. I understand that the activities of this program may include certain physical activities. I/we understand and agree to assume any and all risks associated with the Camp’s activities. In case of illness or injury requiring immediate professional care, I/we, the undersigned parent/guardian authorize necessary medical treatment for my child. I further agree to release the Camp and the Roseville Community Concert Band representatives from any liability for their efforts to secure necessary medical treatment. I agree to cover all costs incurred for medical services and/or medication prescribed. I further agree to absolve the Camp and the Roseville Community Concert Band of any responsibility due to medical complications. I/we grant permission for my child to be photographed for purposes of publicity and understand that some photographs may appear in future publicity.

I/we acknowledge that I/we understand that these voluntary programs are not affiliated with, under the direction of, or operated by the Roseville City School District or the City of Roseville.

Further, I/we acknowledge that I/we enter into this Agreement, and do so knowingly and voluntarily, with complete understanding of the terms and the conditions of the Agreement.

PARENT/GUARDIAN ACKNOWLEDGEMENT *
By checking this box and submitting this form, I/we acknowledge that I/we enter into this Agreement, and do so knowingly and voluntarily, with complete understanding of the terms and the conditions of the Agreement.
Required
How did you hear about our Camp?
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A copy of your responses will be emailed to the address you provided.
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