Medical Consent and Release Form
I give my permission for my child, _____________________________to attend the Fine Arts Funanza Camp. To my knowledge, my
child does not have any medical problems or conditions that would prevent participation in any program activities. I release Fine Arts
Funanza Camp, and all other camp sponsors of any and all liability for any injuries that might occur. I understand that every
reasonable precaution will be taken to protect my child's safety and well-being while he/she is participating in camp activities. I
understand it is my responsibility to check with my private physician regarding any existing medical problems that my child might
presently have that would be a deterrent to his/her participating in the physical aspects of the program. I will inform the staff at camp
of any medical problems my child has at the present. In the event of a medical emergency related to my minor child (listed below), I
hereby request Fine Arts Funanza Camp to contact me at the telephone number listed below. In the event that I, or my spouse,
cannot be contacted, I hereby give my written consent to any hospital, to render whatever emergency medical treatment necessary,
until I, or my spouse, can be contacted. I understand that is my responsibility to check with my private physician regarding any
existing medical costs associated with a student’s injury.
I, _______________________________________ (parent/legal guardian), release Fine Arts Funanza Camp from all liabilities or
responsibilities pertaining to accidents, injuries, or complications resulting from activities. I authorize the Fine Arts Funanza Camp
leadership to transport the above named participant to the nearest hospital, by ambulance or other emergency vehicle, in case of
injury or suspected injury, while the participant is involved in the Summer Program activity. I authorize the hospital's attending
physician to administer necessary emergency professional medical care to the above named participant upon his/her arrival at the
hospital. I understand that while student safety is a high priority under the state law, Fine Arts Funanza Camp is not responsible for
medical costs associated with a student's injury.
Release and Indemnity: Parent, for himself or herself and on behalf of the Camper, agrees a) to release and not to sue Fine Arts
Funanza Camp and their respective owner, employees, other staff and representatives and contractors (“Released parties”) with
respect to any and all claims, demands, actions, causes of action, damages, injuries or losses of any kind (collectively “claims”)
arising in whole or part from Camper’s enrollment, attendance and participation in camp activities and movement about the camp
premises and use of its facilities and equipment. b) to indemnify (“indemnify” meaning to protect and pay claims and damages
including costs and attorneys fees) Released Parties and each of them, from and against any and all claims, by whomever they might
be brought (family members, fellow-campers, and others) arising in whole or part from a loss incurred by, or caused by, Camper. c)
These agreements of release and indemnity include, but are not limited to; claims based in whole or in part on the
negligence (but not gross negligence or intentionally wrongful conduct) of a Released party and extend to all costs and
attorneys fees incurred by Music and Fine Arts.
Loss of Property: Parent understands that neither Fine Arts Funanza Camp nor any other released party is responsible for loss or
damage to Camper’s personal property or possessions in the absence of willful misconduct by such persons. Parents understand that
Fine Arts Funanza Camp STRONGLY discourages campers from bringing valuables such as radios, walkmans, CD players, CDs,
ipods, digital cameras, gameboys, expensive jewelry and mobile communications devices/cell phones. If Camper chooses to bring
such items, Camper does so at his or her sole risk.
Damage to Camp and Other’s Property: Parents understand that Parent shall be liable for any damage to the property or facilities
of Fine Arts Funanza Camp or of the property or facilities of others resulting in whole or in part from acts of Camper.
Refunds: Cancellations received 14 days prior to the start of Camp will receive a full refund. No other refunds will be given.
Photo Release: Parent, for himself or herself and on behalf of the Camper, gives permission and consents to the taking of
photographs, videotapes, and interviews of Camper, and agrees that such photographs, videotapes, or interviews may be published
and used for advertising, promotion, publicity, or recreational viewing by Parent, other Campers and their families and other persons,
in publications and internet web sites related to Fine Arts Funanza Camp and their respective camping activities. Parent, for himself
or herself and on behalf of the Camper waive all claims for any compensation for such use or for damage.
PARENT/LEGAL GUARDIAN (please print): ____________________________________________________________________
SIGNATURE: ____________________________________________________________________________________________
RELATIONSHIP TO MINOR: ______________________________________
DATE: ____________________________
Summer Camp 2015 Application Form
STUDENT NAME: ______________________________________________________________
AGE: _______ DATE OF BIRTH: _________________
(Please Circle)
MALE or FEMALE
Please select Student’s t-Shirt size (circle one):
Youth S
Youth M
Youth L Youth XL
Adult S Adult M
Adult L
Adult XL
HOME ADDRESS: ______________________________________________________________
CITY/STATE/ZIP: ______________________________________________________________
HOME PHONE: _________________________EMAIL:_________________________________
PARENT’S WORK PHONE: ________________________CELL:_________________________
MEDICATIONS TAKEN: _________________________________________________________
ALLERGIES: __________________________________________________________________
SPECIAL MEDICATION PROBLEMS: ______________________________________________
DATE OF LAST TETANUS SHOT: _________________________________________________
CHILD’S PHYSICIAN: _____________________________PHONE #______________________
MEDICAL INSURANCE CO.:________________________PHONE #______________________
POLICY #_____________________________________________________________________
My Student is registering for the following (please check all that apply):

Session 1: Music and Milkshakes June 22-25 …………………….($115.00)

Session 2: Boogie Woogie Barn June 29- July 2

Session 3: Applause July 13 -16 ………………………………………...($115.00)

Extra T-Shirt will be ordered June 1 ……............................……..($10.00)

Late Registration Fee After June 1 ……………………………….....($25.00)
th
nd
th
………….……($115.00)
th
st
st
Total Amount Due $
(Please make your check or Money Order Payable to Fine Arts Funanza)
To finalize your registration please send “The Application Form” and “The Medical Consent Form”
along with payment to:
288 Brandy Ridge Lane
Dickinson, Texas 77539
Attn: Jacquelyn Silva/Fine Arts Funanza
NOTE: Both send “The Application Form” and “The Medical Consent Form” must be completed,
signed and received before the named participant can be assigned to the program
Summer Camp 2015
Fine Arts Funanza has planned
three awesome camps for your child this
summer! Music and Milkshakes kicks off
the summer! The fifties themed show is
June 22nd through June 25th. Boogie
Woogie Barn takes us to Barn Yard with
lots of fun country numbers June 29th
through July 2nd! We will close out the
summer with a Show within a show!
Applause will be held July 13th through
July 16th.
Each Camp will be a completely different show with the
same Camp Schedule. Camp will begin at 9am with an 8am early
drop off for parents working early. Camp will end at 4:30pm and
Thursday the Show will start at 4:30pm for parents, friends and
family to see! Camp details will be attached to the Camp
Calendar. Every day there is a fun event planned! This is a
wonderful opportunity for your child to build confidence in
themselves as well as gaining fine art techniques that will
enhance their ability to perform 
Camp is designed for kids entering Kindergarten through
th
6 Grade. Campers interested in Junior Camper Positions
entering 7th grade and up will need to apply for Fine Arts
Funanza Junior Camp!
If you would like more information on Fine Arts Funanza
please visit us on Facebook or look at our performance videos
on YouTube. Just search Fine Arts Funanza! Or
www.fineartsfunanza.com
Our e-mail address is [email protected] or
you can call (832) 285-6722.