Participant's Name *

First Name

Last Name

Participant's Date of Birth *

MM

DD

YYYY

Instrument Elective Preference *

Please choose your child's preferred instrument elective. As there are only two options, the unselected instrument will be considered a second preference.

Guitar

Fiddle

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Emergency Contact's Name *

First Name

Last Name

Emergency Contact's Phone Number *

(###)

###

####

Primary Physician's Name *

First Name

Last Name

Primary Physician's Phone Number *

(###)

###

####

Media Release *

"Cordova 4H Bluegrass and Old Time Music Camp" may use a photo/s of my child for promotional use. The child's name and other information will not be released.

Yes

No (To respect your choice, the student will not be allowed to be in the end-of-camp photo).

Closed Campus Policy *

For safety's sake, we have a CLOSED CAMPUS policy. We require that a parent or guardian sign their child out at the end of every day, or provide a handwritten note delivered beforehand. There will be a form and clipboard at the front table for you to sign your child out.

I agree to sign my child out at the end of every day, or provide a handwritten note beforehand.

My child may leave campus without my signature. I understand that checking this box will release the Cordova 4H Music Camp of any responsibility for my child after the time that is specified as the end of the day on my student's schedule.

Instrument Loan/Release *

If my child is borrowing an instrument, I agree to take full financial responsibility if my child incurs any damage to that instrument while borrowing it. If my child is using their own instrument, I agree to take full financial responsibility for the instrument that my child is using. I also agree to release Cordova 4H Music Camp of any financial responsibility if any damage is done to the instrument. If my child is loaning an instrument to the camp, I agree to release Cordova 4H Music Camp of any financial responsibility if any damage is done to the instrument during the camp. I also agree that if there is any damage done to the instrument during the camp, the person using it at the time will be financially responsible for the damage done.

Bands Around Town Release

A large part of Cordova 4H Bluegrass and Old Time Music Camp is the Bands Around Town activity on Friday afternoon. Students walk around town with their instructor and a volunteer to play music for locals.

I give my permission for my child to attend the Bands Around Town activity, and understand that the medical release provided with this form extends to the Bands Around Town activity. I also agree that my child will follow instructors' directions, and behave in a way that positively reflects the camp.

Medical Release *

I hereby give my permission to the medical staff selected by the Cooperative Extension Service faculty / staff and Cordova 4H music Camp to order x-rays, routine tests and treatment for the above named youth. In the event I cannot be reached in an emergency, I hereby give my consent to emergency medical treatment, hospitalization or other medical treatment as needed. I will assume all financial obligations incurred if not covered by insurance.

I give permission for emergency medical care * *

Authorization for Emergency Medical Care

First Name

Last Name

Yes, please contact me to volunteer during camp.

Check jobs that you prefer.

Preparing for camp

Camp Set-up

Camp Clean-up

Morning Camp Caretaker (mention preferred days in final comments)

Afternoon Camp Caretaker (mention preferred days in final comments)

Lunch Duty (mention preferred days in final comments)

Evening Family Events (mention preferred days in final comments)

Bands Around Town

Concert Set-up

Concert Clean-up

TELL ME WHERE I'M NEEDED THE MOST

Participant's Name *

First Name

Last Name

Participant's Date of Birth *

MM

DD

YYYY

Private Lesson

Yes, I would like to participate in an optional private lesson.

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Emergency Contact's Name *

First Name

Last Name

Emergency Contact's Phone Number *

(###)

###

####

Primary Physician's Name *

First Name

Last Name

Primary Physician's Phone Number *

(###)

###

####

Media Release *

"Cordova 4H Bluegrass and Old Time Music Camp" may use a photo/s of my child for promotional use. The child's name and other information will not be released.

Yes

No (To respect your choice, the student will not be allowed to be in the end-of-camp photo).

Closed Campus Policy *

For safety's sake, we have a CLOSED CAMPUS policy. We require that a parent or guardian sign their child out at the end of every day, or provide a handwritten note delivered beforehand. There will be a form and clipboard at the front table for you to sign your child out.

I agree to sign my child out at the end of every day, or provide a handwritten note beforehand.

My child may leave campus without my signature. I understand that checking this box will release the Cordova 4H Music Camp of any responsibility for my child at the time that is specified as the end of the day on my student's schedule.

Closed Campus Lunch

My child (must be 13 or older) may leave campus during lunch. We agree that my child will sign in and sign out during lunch, as well as be on time to the next class.

Bands Around Town Release

A large part of Cordova 4H Bluegrass and Old Time Music Camp is the Bands Around Town activity on Friday afternoon. Students walk around town with their instructor and a volunteer to play music for locals.

I give my permission for my child to attend the Bands Around Town activity, and understand that the medical release provided with this form extends to the Bands Around Town activity. I also agree that my child will follow instructors' directions, and behave in a way that positively reflects the camp.

Instrument Loan/Release *

If my child is borrowing an instrument, I agree to take full financial responsibility if my child incurs any damage to that instrument while borrowing it. If my child is using their own instrument, I agree to take full financial responsibility for the instrument that my child is using. I also agree to release "Cordova 4H Bluegrass and Old Time Music Camp" of any financial responsibility if any damage is done to the instrument. If my child is loaning an instrument to the camp, I agree to release "Cordova 4H Bluegrass and Old Time Music Camp" of any financial responsibility if any damage is done to the instrument during the camp. I also agree that if there is any damage done to the instrument during the camp, the person using it at the time will be financially responsible for the damage done.

Medical Release *

I hereby consent to emergency treatment, hospitalization, or other medical treatment as may be necessary by a physician, qualified nurse or hospital in the event of an injury or illness. On behalf of the above student, I hereby waive any liability for injuries/illness sustained at this event "Cordova 4H Bluegrass and Old Time Music Camp". I also hereby accept legal and financial responsibility for the above student in the event of injury or illness.

I give permission for emergency medical care *

Authorization for Emergency Medical Care

First Name

Last Name

Yes, please contact me to volunteer during camp

Check the jobs that you'd prefer.

Preparing for camp

Camp Set-up

Camp Clean-up

Morning Camp Caretaker (mention preferred days in final comments)

Afternoon Camp Caretaker (mention preferred days in final comments)

Lunch Duty (mention preferred days in final comments)

Evening Family Events (mention preferred days in final comments)

Bands Around Town

Concert Set-up

Concert Clean-up

TELL ME WHERE I'M NEEDED THE MOST

Participant's Name *

First Name

Last Name

Private Lesson

Yes, I would like to participate in an optional private lesson.

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Emergency Contact's Name *

First Name

Last Name

Emergency Contact's Phone Number *

(###)

###

####

Primary Physician's Name *

First Name

Last Name

Primary Physician's Phone Number *

(###)

###

####

Media Release *

"Cordova 4H Bluegrass and Old Time Music Camp" may use a photo/s of myself for promotional use. My name and other information will not be released.

Yes

No (To respect your choice, you will not be allowed to be in the end-of-camp photo).

Instrument Loan/Release *

If I am borrowing an instrument, I agree to take full financial responsibility if I incur any damage to that instrument while borrowing it. If I am using their own instrument, I agree to take full financial responsibility for the instrument that I am using. I also agree to release "Cordova 4H Bluegrass and Old Time Music Camp" of any financial responsibility if any damage is done to the instrument. If I am loaning an instrument to the camp, I agree to release "Cordova 4H Bluegrass and Old Time Music Camp" of any financial responsibility if any damage is done to the instrument during the camp. I also agree that if there is any damage done to the instrument during the camp, the person using it at the time will be financially responsible for the damage done.

Medical Release *

I hereby consent to emergency treatment, hospitalization, or other medical treatment as may be necessary by a physician, qualified nurse or hospital in the event of an injury or illness. On behalf of the above student, I hereby waive any liability for injuries/illness sustained at this event "Cordova 4H Bluegrass and Old Time Music Camp". I also hereby accept legal and financial responsibility for the above student in the event of injury or illness.

Yes, please contact me to volunteer during camp.

Check the jobs that you'd prefer.

Preparing for camp

Camp Set-up

Camp Clean-up

Morning Camp Caretaker (mention preferred days in final comments)

Afternoon Camp Caretaker (mention preferred days in final comments)

Lunch Duty (mention preferred days in final comments)

Evening Family Events (mention preferred days in final comments)

Bands Around Town

Concert Set-up

Concert Clean-up

TELL ME WHERE I'M NEEDED THE MOST