NMSA Percussion Camp Medical and Media Release Form

2017 Medical and Media Release Form for summer percussion camp. Please complete this form at time of registration.

I authorize the making and use of any films, photographs, or other recordings of the NMSA percussion camp for NMSA’s internal informational and publicity purposes only.

I understand that NMSA cannot guarantee against the possibility of accident or illness involving my child. I hereby waive and release, on behalf of myself and my child any claim that might be made against NMSA, its directors, officers, employees and agents in connection with any injury or illness my child may incur.

In the event that any serious injury or illness should occur involving my child, I wish NMSA to take all appropriate steps to notify me immediately of the event. If I am inaccessible for any reason, I authorize whatever medical attention is deemed appropriate for my child.

I represent that my child has no medical condition other than noted below that would prohibit participation.

This release is given in consideration of my child’s participation in the NMSA program.

Prospective Student Name Prospective Student Name * First Last
Art Discipline: *

Choose the art discipline that you applied for.
Student Date of Birth Student Date of Birth * / MM / DD YYYY
Today's Date Today's Date * / MM / DD YYYY
Parent/Guardian Name Parent/Guardian Name * First Last
Parent/Guardian Email *
Parent/Guardian Phone Parent/Guardian Phone * - ### - ### ####
Parent/Guardian Signature

I represent to NMSA that I am the parent or legally appointed guardian of the named child, and authorized to sign and deliver this release.

Draw your signature into the box below. *

Clear
Health Insurance/Plan *
Policy Number
Please specify (in detail) any allergies or medical conditions NMSA should be aware of: *
Emergency Contact (in the event Parent/Guardian cannot be reached) Emergency Contact (in the event Parent/Guardian cannot be reached) * First Last
Emergency Contact Relationship to Student *
Emergency Contact Phone Emergency Contact Phone * - ### - ### ####
Secondary Emergency Contact Secondary Emergency Contact First Last
Secondary Emergency Contact Relationship to Student
Secondary Emergency Contact Phone Secondary Emergency Contact Phone - ### - ### ####