Consent Form for Classes and Camps

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)

STEPHANIE 208.313.6044 * stephanieleeandles777@gmail.com

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)