Metro-Capitol Leadership Academy Registration Form

Please double check that all lines are filled in before you hit "submit."

 

MCLA REGISTRATION FORM

Instrument:

What grade will you be in this coming Fall:

Have you held a leadership role before?: If so, what role?:

Current Leadership Role, Ex: Drum Major, Section Leader, Principal Player (Concert Band Track Only):

T-Shirt size (Adult sizes only-S, M, L, XL, XXL):

Student Email: Student Cell Phone:

PARENT/GUARDIAN INFORMATION
Parent Name (main contact for this camp, first and last): Home Phone:

Street Address: City: Zip:

Parent Email: Parent(s) Cell:

Alternate Contact Name (emergency): Alternate Contact (emergency) Cell:

PARENT PERMISSION
I give my child, the aforementioned, permission to participate in the 2017 Metro-Capitol Leadership Academy.
I give permission for my child to participate in daily recreational activities, under the supervision of a licensed physical educator.
I am aware of the inherent dangers and risks involved in outdoor activities and:
I understand that Metro-Capitol Leadership Academy or its parent company Northwest Music and Leadership Academies does not provide any accident or medical insurance for my child. I understand that I am required to provide accident/medical insurance for my child and do so under the policy listed below. I agree that I am financially responsible for any and all medical expenses associated with my child’s participation in this program.

Medical Insurance Provider: Policy Number:
Parent Signature: Date:
(NOTE: Your child will not be allowed to participate in camp unless your medical insurance provider and policy number is provided above.)

HOLD HARMLESS
I agree on behalf of myself, my child, and our assigns, executors, and heirs, to indemnify and hold harmless, Metro-Capitol Leadership Academy, Northwest Music and Leadership Academies, and its employees from any and all liability, damage and claims of any nature arising out of or in any way related to my child’s participation in this program except those things caused by the sole negligence of Metro Leadership Academy.

I understand that the terms of this agreement are legally binding and certify that I have signed this agreement of my own free will after carefully reading and fully understanding it.

Parent Signature: Date:
(NOTE: Your child will not be allowed to participate in camp unless your signature is provided above.)

MEDICAL RELEASE
List any allergies of the student:
May staff administer Tylenol or Ibuprofen? (yes or no):
If necessary, do you grant the directors and staff to administer minor medical treatment and/or if needed to seek additional medical treatment, including transportation to a hospital? (yes or no):
Parent Signature: Date:

STUDENT BEHAVIOR CONTRACT AND PARENT AGREEMENT
As a participant in the Academy, I agree to the following:
1. To cooperate fully with the staff and high school assistants.
2. To attend all sessions, on time, except in the case of illness.
3. To be respectful of the Sherwood HS Performing Arts Center, its rooms and equipment.
4. To return all instruments/equipment at the end of the camp.
5. To put forth my best effort in the leadership training, and to HAVE FUN!

Failure to follow the rules listed above could result in dismissal from the camp. In this case,
registration fees will not be refunded.

Student Signature: Date:

I understand the aforementioned responsibilities, and hereby give permission for the student
listed above to participate in the camp.

Parent Signature: Date:

PHOTO RELEASE
On occasion, camp pictures will be taken for promotional materials. Most of these are large group photos or action shots of multiple students.

By signing below, I hereby ALLOW the camp to use a photo that my child is in.
Parent Signature: Date:
(NOTE: Your child will not be included in any "up close" photos unless your signature is provided above.)

PAYMENT INFORMATION
FOR REGISTRATION TO BE COMPLETED ONLINE, YOU MUST PAY ONLINE OR SEND A CHECK.
Camp Fee: $230 (if paid by June 1), $270 (if paid on or after June 2)
Please indicate any school scholarship (please list school, director, and amount you are receiving):
How will you be paying for the camp (online or sending a check?):
Online Payment Options include Visa/Mastercard: Visit the MCLA Web page to access the Paypal Button. nmla.net/mcla.html
If paying by check, please mail to the addess below, make checks payable to: Northwest Music and Leadership Academies or NMLA
PLEASE SEND CHECK PAYMENTS TO:
NMLA
1479 Coho Ct. NW
Salem, OR 97304