C4A Registration Form: 2019 Summer Workshops & Ensembles
This form is to register for 2019 Summer Programs for older school aged kids, teens and adults.

To register for Day Camps for kids please use this form:
https://docs.google.com/forms/d/e/1FAIpQLSeGHpFpitchQ0v8YcT1LhOcDA8RJjrDZrV5a2AB6qqUjVsiPw/viewform

Please see our website for details, including dates.
http://c-4a.org/summer-programs/

One person may enroll for multiple programs on one form. Additional people need a separate form.

Student's first name *
Your answer
Student's last name *
Your answer
Student's age as of June 1, 2019 *
Your answer
I want to sign up for these workshops/ensembles for all kids from middle/late grade school through high school age!
I want to sign up for these workshops just for teens!
I want to sign up for these group classes for adults and upper teens:
I want to sign up for these ensembles for adults and high school aged kids:
Your instrument, and other instruments you play
Your answer
Participant Information
Please enter information about the participant here.
Student First Name *
Your answer
Student Last Name *
Your answer
If an underage participant receives email and wants updates, please list their email address here.
Your answer
Parent/Guardian/Adult Participant
First Name *
Your answer
Last Name *
Your answer
Email *
Your answer
Phone *
Your answer
Optional: Additional parent or guardian for underaged participants
Parent 2 First Name
Your answer
Parent 2 Last Name
Your answer
Parent 2 Email
Your answer
Parent 2 Phone Number
Your answer
Mailing address
Street Address *
Your answer
Street Address Line 2
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Emergency Contact Information
If there is an emergency, who should we call?
First Name *
Your answer
Last Name *
Your answer
Relationship
Phone Number *
Your answer
Alt Phone Number
Your answer
Medical Concerns?
Does participant have any medical conditions, concerns, or modifications we should be aware of? This information will be shared only with relevant C4A staff. *
Medical details
Your answer
Payment options
You will receive an email invoice within a few days of submitting this registration form. This invoice will offer you the option of paying by electronic check with no extra charge.

Your invoice will also offer a way to pay using your credit card. A $4.95 service fee applies for each credit card transaction.

You may pay with hard copy check made out to C4A and mailed to us a 103 North Race St, Urbana, IL 61801 or deposited in one of our onsite drop boxes.

You may also pay with cash at our front desk at 202 West Main St in Urbana. Our desk is staffed Monday-Friday from 10:30 am to 2:00pm. You may also find us there during other hours.

Finalizing Your Registration
I understand that at non-refundable $25 deposit is required for each activity that I register for, and is due as soon as my registration has been confirmed.

I understand that payment must be made in full at least 2 weeks before the start of each activity that I register for, and that I may forfeit my place if payment is not made.

Payment may be made by check or cash. Payment via electronic check or credit card is available through our emailed invoicing. PayPal is available on our website.

Please read and understand the Consent and Acknowledgement and Medical Release and Authorization below and then sign in the Confirmation Area below before submitting this form.

Contact me About
Would you like to receive our newsletters? Please check all that apply. *
Required
How did you hear about C4A?
Questions? Comments? Suggestions?
Your answer
Informed Consent and Acknowledgement
I hereby give my approval for my child’s (or my) participation in any and all activities prepared by the Community Center for the Arts during the selected activities(s). In exchange for the acceptance of said student's candidacy by the Community Center for the Arts, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Community Center for the Arts, and all its respective officers, agents, and representatives from any and all liability for injuries to said student arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to said student, I hereby waive all claims against the Community Center for the Arts including all instructors, staff, and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Photographs taken during our activities may be used for our promotional purposes without your further consent. We will not publish or release photos that are inappropreate or identify students by name or otherwise reveal their identities.

Students' names may be listed in programs, on CDs or DVDs, or other media. They will not be listed in a way that identifies individuals. Said media will be available to the student and his/her family.

Most activities will take place on C4A premises, but there may be off-site activities that are announced in advance.

Students, their families, and their guests are all responsible for their own safety during participation in our events, whether on or off our premises.

Students, their families, and their guests are all responsible for their own belongings and equipment during participation in our events, whether on or off our premises.

Medical Release and Authorization
As Parent and/or Guardian of the named student, 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 student. 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 Community Center for the Arts and its affiliates including Directors, teachers, staff, and volunteers 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.

*If an adult student, the same release and authorizations apply, with contact attempt being made with designee listed under emergency contacts.

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.
Adult participant or Parent/guardian of underaged participant may sign by typing name here: *
Your answer
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