Performance Academy
Name
Address
Home Phone Cell Phone
Email address
Emergency Contact
Emergency Contact Phone
Allergies (please list):
Camp or Class:
Talent Release:
I give my permission for
Performance Academy to use any photographic image taken of me to be
used in printed publications, on the internet or in other electronic
formats for press or print purposes. If my image is used, I hereby
consent, without further consideration or compensation to the use of
images taken of me for the purposes of illustration, advertising or
distribution of any manner. I understand that the images remain
property and that there will be no restrictions. I accept that no
payment is due in respect of this authority and that no further
payments to me are required at any time.
Informed Consent and Hold
Harmless/Release Agreement:
I understand that participation
in Performance Academy activities involve certain degrees of risk. I
have carefully considered the risk involved and have given consent
for myself and/or my child to participate in these activities. I
understand that participation in these activities is entirely
voluntary and requires participants to abide by applicable rules and
standards of conduct. I release, hold harmless and agree to indemnify
Performance Academy or Stephanie Lowry, and all employees,
volunteers, related parties or other organizations associated with
the activity from any and all claims or liability arising out of this
participation.
I approve the sharing of the
information on this form with Performance Academy staff and
volunteers who need to know of medical situations that might require
special consideration for the safe conducting of activities.
In case of an emergency involving
me or my child, I understand that every effort will be made to
contact the individual listed as the emergency contact person. In the
event that this person cannot be reached, permission is hereby given
to the medical provider selected by the adult leader in charge to
secure proper treatment, including hospitalization, anesthesia,
surgery or injections of medication for me or my child. Medical
providers are authorized to disclose to the adult in charge
examination findings, test results, and treatment provide for
purposes of medical evaluation of the participant, follow-up and
communication with the participant’s parents or guardian, and/or
determination of the participant’s ability to continue in the
program activities. I understand and agree that medical decisions
related to care and treatment may be based upon information supplied
in the appropriate health form submitted.
I have read and understand all
the information shared in this form. If any information I/we have
provided is found
to be inaccurate, it may
limit and/or eliminate the opportunity for participation in any event
or activity.
Participant’s name Date:
Participant’s signature
(Parent or Guardian if under the age of 18)
PRIVATE LESSONS AVAILABLE!!
Piano - $15 per ½ hr (ear, classical training,
or both)
Guitar - $15 per ½ hr
Bass Guitar - $15 per ½ hr
Violin or Fiddle - $15 per ½ hr
Voice - $18 per ½ hr
(CAN HAVE UP TO 3 PEOPLE AND DO A GROUP LESSON)
