Application Form | School of Music | Memorial University of Newfoundland

Student Details

First Name

Last Name

Age

Grade (Upcoming Fall)

Instrument

School

Band Director/Teacher

Do you take private lessons?

Yes

If yes, who is your private teacher?

Address

Street Address

Street Address (optional)

City

Province

Postal Code

E-Mail Contact

Email Address

Parents/Guardians

Name

Work Phone

Home Phone

Cell Phone

Name

Work Phone

Home Phone

Cell Phone

Emergency and Medical Information

Student MCP Number

Expiry Date

Physician

Phone Number

1st Emergency Contact

Name

Relationship to student

Daytime Phone

Evening Phone

2nd Emergency Contact

Name

Relationship to student

Daytime Phone

Evening Phone

Does your child have any physical or medical conditions (including behavioral) or taking any medication which might impact or create a hazard while participating in camp which t he institution, the instructors or supervisors of the camp should be aware? If yes, please explain:

I give permission for Camp Staff to give my child the following medications, if needed.

Tylenol

Advil

Cough

Cough Drops

Sudafed

Benadryl

Other (see below)

If you checked "Other", please provide name of medications not listed above that may be administered, including any prescription medication such as asthma or allergy medication. Prescription medication must be in original packaging which includes dosage.

Emergency Authorization

In the event that I or any of the emergency contacts cannot be reached, I hereby consent and give my permission to Memorial University of Newfoundland and/or the School of Music and the medical personnel selected by them to render such emergency medical diagnosis and treatment to my Child while attending the festival as is deemed necessary. Such authorization for emergency treatment shall also include, but is not be limited to, costs incurred for the provision of such aid and treatment that is medically necessary. I understand and acknowledge that these costs are my responsibility and I will assume financial responsibility for the cost of any specialized means and necessary medical care.

Waiver

I understand that the University assumes no responsibility for personal injury or loss or damage to my Child’s personal property.

I agree to release and waive liability for all claims that I or my Child may have, or may in the future have, against Memorial University of Newfoundland and/or the School of Music, or any person(s), entities or organization(s) associate d in any way with the festival, from any and all liability for any loss, damage, injury or expense that my Child may have suffered as a result of his/her participation or presence at the festival, due to any cause whatsoever.

I declare that I, by submitting this form electronically, am legally authorized to submit this Consent/Waiver Form and hereby give my full consent for my Child to participate in the activities and conditions cited above, I have read, und erstood and agree to the contents of this CONSENT/WAIVER FORM in its entirety and by electronically submitting it freely and voluntarily without any inducement.

I understand and consent to the above information concerning the Emergency Authorization and Waiver *

Images and voice recordings may be taken throughout the program. These images may appear in a wide variety of formats and media now available and those that may be available in the future including but not limited to print, broadcast, videotape, CD-ROM, and electronic/online media. I authorize the University to publish these recordings for educational or promotional purposes in any type of media.

I consent to publication of images and/or voice recordings

I decline consent to publication of images and/or voice recordings