2019 APV Summer Camp Registration Form
Please note that all fields followed by an asterisk must be filled in.
Parent/Guardian First Name*
Parent/Guardian Last Name*
E-Mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Cell Phone*
Camper's Name*
Age *
---Select--- 5
6
7
8
9
10
11
12
School
Please list ADA Accommodations needed
Single Day Camper-Please specify Date
Extended Day Hours 6:30am-7:00pm (Additional $20/week)*
Approved Child Pick Up (Provide first and last name)*
Emergency Contacts (provide first/last name, relation to child and phone number)*
Do you authorize OPMI to use photos of your child on our website and/or promotional material?
Payment FOR WEEK ONE due by May 31st - Payment Type (payments are due each Friday before camp starts)
Statement of Understanding*
Statement of Understanding*
LIABILITY WAIVER*
BY CHECKING THIS BOX, I AGREE THAT I HAVE READ AND VOLUNTARILY SIGNED THIS AGREEMENT ELECTRONICALLY and further agree that no oral representation, statements, or inducement apart from the following written agreement has been made: IN CONSIDERATION, of being permitted to utilize the facilities, services and program of ORLANDO PREMIER MUSIC INSTRUCTION, herein after referred to as 'OPMI', for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with OPMI, the undersigned, for himself or herself and any personal representatives, heirs, children and next of kin, hereby acknowledges, agrees and represents that he or she releases OPMI and its staff members from all liability for an injury, loss or damage connected in any way whatsoever to participation in OPMI activities whether on or off of the premises affiliated with OPMI. He or she understands that this release includes any claims based on negligen
Special Needs/Concerns: