Your Name *

First Name

Last Name

Camper(s) Name *

First Name

Last Name

Phone Number *

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Select Your Session *

June 17 - 21

June 24 - 28

July 8 - 12

July 15 - 19

July 22 - 26

Early/After Care ($30/hr)

If selected, then Early/After care needs for your child will be totaled the week of the camp. Payment will be collected at the end of the week.

Yes!

Camp Participant Release and Waiver *

I authorize and grant permission for a representative of Russo Music to treat minor injuries including scrapes, small cuts, and splinters. I authorize and grant permission for a representative of Russo Music to obtain emergency medical care from any licensed physician or hospital and/or medical clinic should my child become ill or injured. I therefore freely and voluntarily execute this release with such knowledge, assume the risk of personal injury and/or property loss arising from in any way connected with participation in any programs offered by Russo Music. I hereby release and discharge Russo Music and any and all agents of Russo Music from any liability, claim, cause of action, demand or damages from injury or damages of any kind to my child or my property as a result of participation in the programs of Russo Music. I grant permission and understand that photos and other images taken during this event could be used to print advertisement and other forms of media. I understand that should my child become a disruptive force during the educational program that the instructor may chose to release him/her from the program with no refund.

I have read and fully understand the Release and Waiver of Liability and release of all claims. I grant permission and understand that photos and other images taken during Russo Music Camp could be used in promotional materials and other forms of media.

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country