2023 Summer Camp - Music On Wheels Academy

Summer Camp 2023

Note: It is the responsibility of the Parent/Student/Guardian to check e-mails and the website periodically for important updates.

Student Information

Student Information(Required)

First Name Last Name

Email(Required)

Cell Phone(Required)

Gender(Required)

Number(Required)

Please enter a number from 5 to 100.

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Emergency Contact

Emergency Contact Name 1(Required)

Emergency Contact Name 1 Phone(Required)

Emergency Contact Name 2(Required)

Emergency Contact Name 2 Phone(Required)

Authorized Person (s) To Pick-up Child

Authorized Pick Up Name(Required)

Authorized Pick Up Phone(Required)

Add Another ?

Yes

Authorized Pick Up Name 2(Required)

Authorized Pick Up Phone 2(Required)

Summer Camp Tuition

(Whole/Half Day) *(Required)

Camp Fee

Price: $0.00

Total

Payment Information

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Medical / Special Needs

Does your child have any specific medical conditions or behavioral problems?(Required)

Yes

List any specific medical conditions or behavioral problems? * (NOTE: Music On Wheels, LLC and The Miracle Foundation Of Arts & Academics DOES NOT administer medication to students)(Required)

Does your child have any other allergies (food, hay fever, etc.)? *(Required)

Yes

List any other allergies (food, hay fever, etc.)(Required)

Are there conditions or specific needs that require special attention?(Required)

Yes

List all conditions or specific needs that require special attention(Required)

Consents & Waivers

Waiver

ACCIDENT WAIVER, LICENSURE EXEMPTION, AND RELEASE OF LIABILITY FORM (Type FULL Name In Acknowledgement) * I HEREBY ASSUME ALL OF THE RISKS ALLOWING MY CHILD TO PARTICIPATE IN THIS SUMMER CAMP ACTIVITY OR EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of The Miracle Foundation Of Arts & Academics, Inc. and Music On Wheels, LLC and/or Restoring The Years Global Ministries, and/or the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault. I certify that I my child/or children are physically fit, and have sufficiently prepared or trained for participation in the activity or event, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems, which preclude my child’s participation in this activity or event. I acknowledge that this Accident Waiver and Release of Liability Form will be used by The Miracle Foundation Of Arts & Academics, Inc. and Music On Wheels, LLC , the event holders Restoring The Years Global Ministries, sponsors, and organizers of the activity or event in which my child participates, and that it will govern my child’s actions and responsibilities at said activity or event. In consideration of my application and permitting my child to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: The Miracle Foundation Of Arts & Academics, Inc. and Music On Wheels, LLC and/or Restoring The Years Global Ministries, and/or their directors, officers, employees, volunteers, representatives, and agents, the activity or event holders, activity or event sponsors, activity or event volunteers; (B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of release or otherwise. I acknowledge that The Miracle Foundation Of Arts & Academics, Inc. and Music On Wheels, LLC and Restoring The Years Ministries, and/or their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific event or activity on behalf of The Miracle Foundation Of Arts & Academics, Inc. and Music On Wheels, LLC, as well as Restoring The Years Ministries. I acknowledge that this activity or event may involve a test of a person’s physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to participants, but are also present for volunteers. I hereby consent my child to receive medical treatment, which may be deemed advisable in the event of injury, accident, and/or illness during this activity or event. The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. PHOTOGRAPHY & VIDEO I also understand that at this event or related activities, my child may be photographed or videotaped in activities described within the camp only. I agree to allow photos, video, Internet advertisement, and/or film to be used for any legitimate purpose by the event holders, producers, sponsors, organizers, for marketing, informational or educational purposes of the camp. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL. The undersigned parent and natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward’s participation in the activity or event, and has agreed individually and on behalf of the child or ward, to the terms of the accident waiver and release of liability set forth above: The Miracle Foundation Of Arts & Academics, Inc. and Music On Wheels, LLC and Restoring The Years Ministries, and/or their directors, officers, volunteers, representatives, and agents. The undersigned parent or guardian further agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian. (Type Full Name In Acknowledgement)) Policies & Procedures (READ and TYPE FULL NAME IN ACKNOWLEDGEMENT) * Enrollment begins after your child is registered and the 1st week of tuition is paid. Full Tuition is due the 1st Monday of each week. A $35.00 late fee will apply on payments received after Monday. Partial weekly tuition payment will not be accepted. If payments are not received by Tuesday, your child will not be able to attend camp unless the account is paid current along with the late fee. Parents may choose to pay for more than one week to avoid late fees.We accept check and/or credit card payments. There are no refunds. All fees paid are non-refundable. Our organization does not pro-rate days due to absences or holidays. Children must be picked up on time. Camp full day hours are from 8:00am to 5:00pm. Camp half-day hours are 8:00am to 12:30pm. Children picked up late will incur a $1.00 per minute fee. A $35.00 NSF fee will be charged to all returned checks. For the benefit of the camp, certain behavior is expected of all students. If all efforts to make this happen fail, The Miracle Foundation Of Arts & Academics, Inc. and Music on Wheels, LLC reserves the right to withdraw a student from the camp.

Signature(Required)

Name

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