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 InformationStudent Information(Required) First Name Last Name Email(Required) Cell Phone(Required)Gender(Required)Choose GenderMaleFemaleNumber(Required)Please enter a number from 5 to 100.Address(Required) Street Address City State / Province / Region ZIP / Postal Code Emergency ContactEmergency 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 ChildAuthorized 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)Please choose an option$185 | Whole Day Weekly (Mon-Fri 8AM – 5PM)$135 | Half Day Weekly (Mon-Fri 8AM – 12:30PM)Camp Fee Price: $0.00 Total Payment InformationCredit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Medical / Special NeedsDoes your child have any specific medical conditions or behavioral problems?(Required) Yes No 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 No List any other allergies (food, hay fever, etc.)(Required)Are there conditions or specific needs that require special attention?(Required) Yes No List all conditions or specific needs that require special attention(Required)Consents & WaiversConsent(Required) I consent to my child participating in Summer Camp sponsored by Music On Wheels, LLC and The Miracle Foundation Of Arts & Academics *Consent(Required) The information listed on this health information form is correct to the best of my knowledge, and the camper described herein has permission to engage in all prescribed camp activities, except as noted on this form. I also understand that Music On Wheels, LLC and The Miracle Foundation Of Arts & Academics DOES NOT administer medication to students. (Type Full Name in Acknowledgement)Consent(Required) As parent/legal guardian, I authorize Music On Wheels, LLC and The Miracle Foundation Of Arts & Academics personnel and/or staff to seek emergency treatment as required and to transport my child to the appropriate medical facility in the event that urgent/emergency care is necessary. (Type Full Name In Acknowledgement) *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.Consent I have read, understood and accepted all policies and procedures required by The Miracle Foundation Of Arts & Academics, Inc. and Music On Wheels, LLC (Type Full Name In Acknowledgement)Signature(Required)PhoneThis field is for validation purposes and should be left unchanged. Δ
