Registration Forms

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Rock and Roll Camp Valencia REGISTRATION FORM

 

PAGE 1

In order to secure your space, please fill out all the pages in this packet and submit your payment

(with check made out to Valencia College) to:

Rock and Roll Camp, Valencia College

ATTN: Arts & Entertainment 3-2

P.O. Box 3028

Orlando, FL 32802-3028

 

CAMPER INFORMATION

Camper’s Name: _____________________________________ Age: _______ DOB: _______________

Address: __________________________________________ __________________________________

Grade in the fall of 2017*: ___________

Email: Please be Legible here!___________________________________________________________

Home Phone: ______________________Camper's Regular School: _____________________________

Instrument (Guitar, Drums, Bass, Voice, Trumpet, etc.): _______________________________________

T-shirt size (circle one): Y/S, Y/M, Y/L, A/S, A/M, A/L, XL, 2X/L

Please describe the camper’s previous musical experience: ____________________________________

____________________________________________________________________________________

 

PARENT INFORMATION

Mother/Guardian: _________________________________ Cell: __________________________

Place of Work: _________________________________ Phone: __________________________

Father/Guardian: __________________________________ Cell: _________________________

Place of Work: _________________________________ Phone: __________________________

 

PROGRAM REGISTRATION: Please mark each week of camp for which they are registering.

You are responsible for payment for each week that you select below:

Please check which week(s) you are attending

WEEK 1: June 5-9, 2017    $320__________

WEEK 2: July 24-28, 2017 $320__________

($20 discount for a student attending both weeks)

 

MEDICAL INFORMATION

Medication cannot be administered by Music Camp staff. If a camper will require medication during the day,

the parent or guardian may come to the camp to administer it.

1. Does your child have any medical condition, learning disability, or other special needs?

__________________________________________________________________________________________

2. Does your child have any allergies?

__________________________________________________________________________________________

3. Does your child have any behavioral issues?

__________________________________________________________________________________________

4. Please provide Medical Insurance information:

__________________________________________________________________________________________

5. Please provide your Doctor’s name and telephone number.

__________________________________________________________________________________________

 

PAGE 2: EMERGENCY CONTACT & PICK-UP FORM

 

Camper’s Name: _________________________________________                Age: _____________

 

EMERGENCY CONTACT LIST                             CAN PICK UP? YES/NO

 

Name: _______________________ Relationship: _________________ Phone: ________________ _______

 

Name: _______________________ Relationship: _________________ Phone: ________________ _______

 

Name: _______________________ Relationship: _________________ Phone: ________________ _______

 

AUTHORIZED PICK]UP LIST

 

Please write the names of any other individuals authorized to pick up your child. Children will be released only to

individuals on this list. You must inform them to bring a PHOTO ID for pick up. Parents should report to the

circular drive outside of the East Campus Performing Arts Center for pick up.

 

NOTE: It is illegal to leave children unattended. Children may not be left at the camp before 8:30 a.m. or after 4:00

p.m. regardless of staff members present.

There will be a $5.00 charge for late for pick up within the first 10 minutes and then $1.00 per minute thereafter.

Campers with unpaid balances will not be permitted to attend.

 

Name: _______________________ Relationship: _________________ Phone: ________________

 

Name: _______________________ Relationship: _________________ Phone: ________________

 

Name: _______________________ Relationship: _________________ Phone: ________________

  

PAYMENT, CANCELLATION, & REFUNDS

 Camper’s Name: _________________________________________                Age: _____________

 I have read and understand the refund and cancellation policy.

 

___________________________________________ _____________________________

Signature Date

___________________________________________

Print Name

Please tear off the bottom portion and retain for your records.

 

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TUITION & FEES

 

1. Course fees include: Music instruction, course materials, activities, supplies.

 

2. Course fees DO NOT include: lunch.

 

3. The weekly fee is due at the time of registration. If you register your child for multiple weeks, you must pay the

first week's fee. The fee for each upcoming week is due on the Wednesday prior to that week, or a $20.00 late fee will be added .

If you checkmark multiple weeks, you are responsible for payment of those weeks and the cancellation/refund policy will apply.

 

4. Space is limited. Maximum group size is 40 children.

 

5. Checks returned for insufficient funds will be charged an additional $25 fee.

 

REFUND & CANCELLATION POLICY

1. If a section is cancelled by the college, you will be given a complete refund.

 

2. If you decide to cancel your registration, you will be given a 100 percent refund if you contact the Camp Director

at least 5 business days prior to the camper's program start date. There are no refunds once the program

week has started.

 

3. All requests for refunds and cancellations must be submitted in WRITING to
4. boxoffice@valenciaccollege.edu or sent to the address listed above.

 

4. If you are registered for a program week and need to change to a different program week, the cancellation

policy still applies as stated above.

 

5. There is no refund if your child is dismissed from camp for inappropriate behavior. There is no refund for any

days that your child did not attend camp due to illness or vacation.

 

Please make payment out to : Valencia College Music Camps

  _______________________________________________________________________________________________

PAGE 3: WAIVER & RELEASE

 

Camper’s Name: _________________________________________                Age: _____________

 

As the duly authorized agent of the child, I have read this release and indemnification and understand all of its

terms. This release and indemnification agreement is executed voluntarily and with full knowledge of its contents

and significance.

 

________________________________________                     ___________________________________

Duly Authorized Representative for the Child                                     Date

________________________________________

Print Name Here

 

Please tear off the bottom portion and retain for your records.

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The above]signed representative, on behalf of the child named above (hereinafter “the child”),

who desires to participate in Summer Music Camp at Valencia,

and in consideration of being permitted to participate in said activity,

voluntarily and knowingly executes this release and indemnity agreement on behalf of the

child with the express intention of extinguishing the rights and obligations designated herein. The undersigned

representative, on behalf of the child, hereby grants the Summer Music Camp at Valencia staff

the permission to provide treatment for emergency and/or minor medical injuries or illnesses

which may arise while the child is participating in the camp.

 

As representative of the child, I hereby elect to and assume all risks for claims hereinafter arising, known or

unknown, from the conduct of the Summer Music Camp at Valencia and hereby knowingly and voluntarily expressly release Valencia College,

its employees, agents, representatives, officers, directors, or others acting on behalf of Valencia College,

from all liability for claims arising out of such matters.

 With the intention of binding the child and with full authority to do so, I hereby release, discharge, and indemnify

Valencia College, its employees, agents, representatives, officers, directors, or others acting on behalf

of Valencia College, from any and all claims, demands, actions, judgments, and executions which the

child ever had, nor now has, or ever will have, or which the child may claim to have against Valencia College,

its employees, agents, representatives, officers, directors, or others acting on behalf of Valencia College,

in connection with or arising out of, directly or indirectly, any and all matters relating to the Summer Music Camp at Valencia,

including any alleged acts of negligence by the College’s employees, agents, representatives, officers,

directors or others acting on behalf of Valencia College.

 

As the duly authorized agent of the child, I give my permission to Summer Music Camp at Valencia to use,

without limitation or obligation, photographs, film footage, or tape recordings, which may include the child,

my family’s image, or me for the purpose of promoting the Summer Music Camp at Valencia.           

 _____________________________________________________________________________________

 

PAGE 4: DISCIPLINE AGREEMENT FORM

 

Camper’s Name: _________________________________________                Age: _____________

 

I, _____________________________________ (camper’s name) and __________________________________

(parent’s name) hereby acknowledge that we have read and discussed this policy. We understand and agree to

abide by all terms and conditions.

___________________________________                   _____________________________________

Camper’s Signature Parent’s                                                      Signature

___________________________________                   _____________________________________

Date                                                                                                      Date

 

Please tear off the bottom portion and retain for your records.

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TO ALL CAMPERS AND PARENTS: Please read this Discipline Policy and acknowledge your agreement with the

terms by signing below. Tear off the bottom portion of this form and return it with your registration paperwork.

 

Discipline is necessary for an effective program. Our philosophy is respect, praise, and positive reinforcement for all.

In an effort to provide your child and others with a safe and fun]filled summer music camp experience, it is

important that all campers exhibit proper behavior and self]control.

Correcting inappropriate behavior is time consuming and detracts from providing quality, safe, and enjoyable activities for all campers.

If campers behave in a manner that is unsatisfactory, we will employ methods of positive redirecting and reinforcement and the use of

“time]outs.” Examples of inappropriate behavior include, but are not limited to: fighting, bullying, name calling,

foul language, arguing, lying, reckless endangerment, disrespectful actions, stealing, spitting, or ignoring adult

instructions.

 

Some of the rules that must be followed by all campers include:

 

• You must always wear your nametag.
• You must stay with your instructor at all times throughout the day.
• Treat others with respect and kindness.
• Show respect to the property of others and school property.
• Use “inside voices” when in the classroom.
• Keep your hands to yourself.
• No running throughout the building.
• Clean up after yourself.

Safe and appropriate dress is required for onstage performances.

 

 

When camp staff members experience repeated inappropriate or unsatisfactory behavior, that camper will first be

issued a verbal warning and instructed on how to correct the behavior. A second offense will result in counseling

with the program coordinator or management staff. A third offense will result in a phone call to the parent or

guardian to address the situation. If the behavior persists, we reserve the right to require the parent or guardian to

pick up the child from camp immediately. Should the behavior persist, we reserve the right to expel the child from

the camp with no tuition reimbursement. In the case of behavior that endangers property or the safety and welfare of others,

the faculty reserve the right to have parents remove the child immediately without reimbursement.