STUDENT ENROLLMENT FORM - Please complete and submit one form per child.
Child's Name Date of Birth
Address of Residence
___________________________ ________________________________ ______________________________ _______________________________
Home Phone Cellular Phone Home Phone Cellular Phone
e-mail address e-mail address
Allergies, Reaction, Treatment
Illness or Medical Conditions
Notes regarding any learning disabilities, eyesight, or reading limitations.
Additional Concerns or Comments:
Emergency Contacts other than Parents Relationship
Home Phone Cell Phone
EMERGENCY RELEASE AUTHORIZATION
In case of illness or accidental injury of my child ________________________________________________, I hereby authorize Linda Haddix, or any volunteers and/or participants present during classes and/or activities held at 5201 W. 109th Avenue, Crown Point, Indiana, to send for or seek medical assistance. I agree that Linda Haddix or anyone assisting with classes and activities, may call upon his or her local medical hospital or ambulance. All costs incurred are the responsibility of the parent or guardian.
WAIVER AND RELEASE OF LIABILITY
THIS FORM MUST BE READ AND SIGNED BEFORE THE PARTICPANT IS ALLOWED TO TAKE PART IN ANY CLASS OR ACTIVITIES
Release of Liability, waiver of claims, assumption of risk, and indemnity agreement,
between all volunteers in association with Harmony Handbells and Hillside Community Church.
Name of Participating Child (RELEASEE)
By signing this document you will have agreed to waive certain legal rights, including the right to sue.
IN CONSIDERATION of being permitted to participate in any way in the classes, activities or concerts affiliated with Harmony Handbells. The undersigned acknowledges, understands, and agrees that:
I/We hereby release and hold harmless, Harmony Handbells and all volunteering officers, and all owners or lessors of the participating premises, other participants and volunteers associated with classes and activities held. With respect to any and all injury, disability or death, or loss or damage to person or property. Whether caused by the negligence of the releasee or otherwise. I assume full responsibility for my child's/children's presence and participation, as well as my own presence and participation.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Please submit one form per participating child. Thank you!
We are a non-profit organiztion, and all positions are filled by volunteers. However, there are some costs involved in our yearly children's program. The fee is $65.00 for your first child, and $50.00 for each additional child. Due to the expense of online payments, we'd appreciate payments at our first practice on September 14th. Thank you.
The registration fee is $65 for your first child, and $50 for each additional child.
You can submit your registration form online, and pay at our first practice on September 14th. Registration forms will also be available if you're unable to register online. Thanks!
How did you hear about us?
By registering for Harmony Handbells, I give permission for pictures and/or videos of any practice or event to be used in the printing of publicity materials, as well as posted to Facebook, YouTube and our website. Pictures and/or videos will be used for the purpose of sharing or promoting events with the supporting community as well as for our personal use for student practice. Individual names will not be used to identify any minors pictured.