Student Name *

First Name

Last Name

Student Birthdate *

Please confirm year is correct.

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DD

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Student Ethnicity (Optional)

White/Caucasian

Hispanic/Latino

Asian/Pacific Islander

Black/African American

Native American/Alaskan Native

Other

Best Phone Number for Calls/Texts *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian First and Last Name *

Adult students, please type in N/A.

First Name

Last Name

Additional Phone Numbers

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Photo/Video Waiver *

By enrolling as a student or entering the facility at OC Music and Dance, I agree to allow, without compensation, my (or my child’s) likeness, name, voice, photograph, performance and/or biography to appear, and to otherwise be used, in material, regardless of media form, promoting OCMD and its partners, including those of its representatives and licensees. I hereby assign to OCMD, all present and future copyright and all other rights, title and interest that I (for myself or on behalf of my child) may hold in the media. I hereby further agree that I, for myself (or my child), will not make any claim for further remuneration against OCMD, its licensees or assignees in respect of the use of such media. I understand that in order to opt out of this photo and video release, I must email this request to lindsay@ocmusicdance.org.

I agree to the photo/video release,

I will email to opt out of the photo/video release.

Liability and Medical Waivers *

Liability Waiver: I understand that my (or my minor child's) participation as a student could include actions or tasks which might be hazardous to myself (or child), including the impact of the coronavirus. In addition, I accept that, notwithstanding OCMD’s Health and Safety Policies, there are still risks that these efforts might not prevent myself, my child, or other members of my family, from contracting the disease. By accepting below, I assume any and all risks of harm or injury which may occur to me (or my child) during my (or my child's) participation, except for reasons of gross negligence or neglect by OCMD. I, for myself (or on behalf of my child) release and agree to hold harmless OCMD, its teachers, staff, volunteers and artistic partners, as well as other participants, from all such liability and costs incurred to recover damages during such participation in class or during events and activities, whether on-site at OCMD or off-site on behalf of OCMD. Medical Waiver: In the event of injury or illness during my child’s participation as a student at OCMD, I hereby authorize OCMD to consent to medical treatment on my child’s behalf as deemed necessary on the advice of trained emergency personnel. I agree that it is my responsibility to obtain and maintain health insurance coverage for my child prior to any participation with OCMD and that I am responsible for any medical expenses arising out of any injury to claim occurring during my child’s participation

I agree to OCMD's Liability and Medical Waivers

Acknowledgment *

By submitting this form, you are acknowledging that the information provided by you is accurate, and that you've read and accepted OCMD's policies and waivers.

I agree.

Student Name *

First Name

Last Name

What date will your student be missing their Musicianship class? *

MM

DD

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What date would you like to make up the missed Musicianship class? *

Make-ups should occur during the same week as the missed class. Please contact lindsay@ocmusicdance.org if you'd like to make-up your missed class in a different week.

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DD

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