The Musical Institute for Youth
Presents
Rock Camp New Mexico

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Rock Camp 2010 Registration Form

 
Please select the session(s) you would like to attend:

  Session 1: (June 7-18)
  Session 2:  (June 21-July 2)
  Session 3:  (July 5-16)
  Session 4: (July 19-30)
Student Information
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Parent/ Guardian Information
First Name:
Last Name:
Contact Information
Daytime Phone:
Evening Phone:
Parent/Guardian Email:
Musical Instrument Preference
  Vocals
  Keyboards
  Drums
  Bass Guitar
  Electric Guitar
What experience (if any) do you have with the instrument of choice?:
Other Information
Name a few of your favorite bands and songs that you might like to learn:
Age of Student:
Does the student have any medical conditions or allergies? Please list:
Does the student need any medications? Please list:
Does the student have any pertinent disabilities?
Emergency Contact One
 (Please list at least name and phone number):
Emergency Contact Two:
I hereby authorize the staff at the Musical Institute for Youth (Rock Camp 2010) to act for the camper according to their best judgment in any emergency requiring medical attention, and I hereby waive and release the Musical Institute for Youth (Rock Camp 2010) from any and all liability for any injuries or illnesses incurred while attending. I understand that participation in the program will involve the use of electrical equipment which carry with them the risk of injury. The Musical Institute for Youth (Rock Camp 2010) is not responsible for personal items that are lost, stolen or damaged. All medical expenses incurred will be the responsibility of the student or student's family. I have no knowledge of any physical or mental impairment that would be affected by the named student's participation in the program. I acknowledge that there will be no refunds of donations for any reason. I also understand that The Musical Institute for Youth (Rock Camp 2010) retains the rights to use any photographs, video-tapes, songs, recordings, or any other record of the event for publicity, advertising, or any legitimate purpose. I further agree to indemnify and hold harmless The Musical Institute for Youth (Rock Camp 2010), their teachers and agents from and against all liability resulting in injury associated with this individual's participation in the program and understand that all terms are subject to change. 
By typing your names below, You agree that this is valid as your signature.
Parent/ Guardian's Signature:
(If student is under 18)
Student's Signature:

       

Suggested Donation is $100 per child per session (two weeks) to cover basic costs including instructors, instruments, snacks, building usage, etc. Please do not feel obligated to pay if you are unable, however without donations Rock Camp would not exist. You can donate by credit card or paypal account below, and we also accept donations by mail and in person.


Food for thought: This program costs us $3.33 per child per hour - that's cheaper than hiring a babysitter!


We appreciate your generosity.  

 
Note about registering: We are working on adjusting this page so that you are redirected after submitting your registration. Until then, when you hit the submit button, there will be no indication that anything happened except that the answers you typed will be erased. Don't worry, your registration form is sent to us, and we'll reply within 48 hours.
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