Bard Music Camp 2019 - Medical and Photo Release Form
Bard Music Camp 2019 - Medical and Photo Release Form
* Indicates required field
MEDICAL INFORMATION
Child's Name
Child's Name
*
First
Last
Child's Date of Birth
Child's Date of Birth
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MM
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DD
YYYY
Allergies (no food is to be provided by Bard Music Camp):
Other Pertinent Medical Information:
PARENT'S NAME
PARENT'S NAME
*
First
Last
PARENT'S EMAIL
*
First Choice Parent/Guardian Name and Number:
*
Emergency Contact Name (in case parents cannot be reached):
*
Emergency Contact Phone Number
Emergency Contact Phone Number
*
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Primary Care Physician Name:
Primary Care Physician Phone Number:
Primary Care Physician Phone Number:
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Please read and check (required):
*
Please read and check (required):
I hereby authorize (his or her) participation in the Bard Music Camp at Bard College for the dates July 1-13, 2019. I further release Bard College, its directors, officers, employees, students, agents, representatives or affiliates, from any and all liability caused in whole or in part by anyone affiliated with Bard College or from any other cause whatsoever, which results in bodily injury or personal injury suffered by above named minor participant and for any loss or loss of use or damage to personal property owned by said participant or family member, or any other damage or injury, which may result due to the above named minor’s visit or use of Bard College facilities during this activity. I further understand that all Bard College employees including faculty, staff and volunteers involved in said visitation will exercise reasonable care and act responsibly while conducting activities of said visitation. I further understand that Bard College does not provide Health Insurance for students during their participation in the Bard Music Camp. Health Insurance is the sole responsibility of the child’s parent(s) or guardian(s).
PHOTO/VIDEO RELEASE FORM FOR CHILDREN UNDER 18 YEARS OF AGE
Please read and check (required):
*
Please read and check (required):
I hereby authorize and consent to the use of his/her visual image and/or audio performances - including but not limited to still photography, videotape, and audio recording - by the Bard Music Camp and Bard Preparatory Division for appropriate purposes including publicity in electronic and print publications and websites. I give consent with no claim for payment. NAME OF CHILD WILL NOT BE DISPLAYED OR PRINTED.
NOTES