1
FULL NAME OF PARENT(S) or GUARDIAN(S)
Parent 1 _______________________________________________
First
Last
Parent 2 ______________________________________________
REGISTRATION FORM
Please Return to: MAMM PO Box 6606. Portland ME 04103
207-899-3433
www.maineacademyofmodernmusic.org
[email protected]
Please enroll __________________________________________
FIRST NAME
LAST NAME
Birth Date _________ / __________ / __________
Month
Day
First
Last
HOME ADDRESS where camper receives mail:
_______________________________________________________
Street Address
_____________________________________________________________________
City/Town
State
Zip
Parent’s email
address:_____________________________________________________
Year
HOME PHONE: (______) __________________________________
_________ Male _________ Female
1. Previous programs/camps attended (if any):
_______________________________________________________
2. How did you learn about our program?
3. List participant’s favorite bands/recording artists:
WORK PHONE: (______)_________________________________
Parent 1
WORK PHONE: (______) _________________________________
Parent 2
CELL PHONE: (______)__________________________________
Parent 1
CELL PHONE: (______) __________________________________
Parent 2
EMERGENCY CONTACT
________________________________Phone: ________________
4. Has participant ever been a band member?
YES NO
5. Has participant had formal instrument or vocal training? If so, for
how long and which instruments?
_____________________________________________________________
6. Does participant perform vocally, or wish to sing in a band?
YES NO
Enrollment is for: (√
√ CHECK ONE)
(See supplement for specific dates & fees)
Rock Camp ________
Hip Hop Camp _________
Drum Camp __________
Recording Camp ________
Guitar Camp ________
DATES of ATTENDANCE: ____________________________
PAYMENT (SEE REFUND POLICY)
PAYMENT IN FULL ENCLOSED ________
Please make check payable to: Maine Academy of Modern Music
Office Use: Ck. Number________ Cash________
RELATIONSHIP to participant: ___________________________
WORK OR CELL PH: ____________________________________
Parent Authorization: The Participant Has Permission To Engage In All Prescribed Camp
Activities Except As Noted By My Physician Or Myself In Writing. I Hereby Give Permission To
The Physician Selected By The Director To Order X-Rays, Routine Tests, And Emergency
Treatment For The Health Of My Child. In The Event I Cannot Be Reached In An Emergency, I
Hereby Give Permission To The Physician Selected By The Director To Hospitalize, Secure Proper
Treatment For And Order Injections And/Or Anesthesia And/Or Surgery For My Child As Named
Above. I Hereby Agree that MAMM’s (Maine Academy of Modern Music) Director may Dispense
Over-the-Counter Medications Where Deemed Necessary. I Hereby Release The Use Of Music,
Photographic And Video Images And Work Product Of The Above Participant For The Purpose Of
Promotion And Display To The General Public. Jurisdiction for the collection of delinquent funds
will be in Cumberland County, Maine and MAMM is entitled to recover all costs and fees incurred in
the collection of judgment plus 1.5% per month fee for all late payments. Jurisdiction for all other
legal action will be in Cumberland County, Maine. Any individual bringing legal action against
MAMM which results in a decision in favor of MAMM will be responsible for all related legal, court,
and out of pocket expenses of MAMM, its owners and employees. I, THE PARENT OR LEGAL
GUARDIAN OF THE ABOVE NAMED CHILD, HAVE READ MAMM POLICIES AND CODE OF
CONDUCT AND AGREE TO ALL TERMS.
REFUND POLICY: There will be no deduction or return of fees for participants sent home
for behavioral problems or for late arrivals or early departures. It is the responsibility of the
participant’s family to pay for all costs incurred due to late arrival or early departure regardless of
the reason, unless otherwise agreed to in writing. No refund is available for discontinuation of the
camp season due to acts of God, natural disaster, acts of war or epidemics. In addition, MAMM will
consider refunds on a pro-rated basis if the participant chooses to withdraw from the program on
DAY ONE of the program. After the first day of program, participants forfeit all fees. Refunds
when issued for medical reasons, will be at the discretion of the Director
I, the parent or legal guardian of the above named child, have
read and explained the MAMM policies with my child
(participant).
Both I and my child (participant) understand these policies.
X____________________________________________________
Parent/Guardian Signature
Date ________________________________
2
7.
STATEMENT OF POLICIES AFFECTING PARENTS
PLEASE READ CAREFULLY
MAMM CODE OF CONDUCT: Please familiarize yourself with the guidelines
described in the “CODE OF CONDUCT” ,which your son/daughter must agree to
observe during his/her participation. The Director reserves the right to withdraw any
camper whose influence or actions are deemed harmful or who will not live within the
rules and policies. The use or possession of alcohol, tobacco, or controlled
substances (drugs) is strictly prohibited in program or on trips. Please make sure that
you clearly describe and discuss these policies with your child before his or her
participation, specifically regarding the use or possession of tobacco while
participating. It is not our wish to send any participant home for disciplinary reasons.
We also reserve the right to withdraw participants who arrive at the program with
preexisting injuries, medical or mental health problems which have not been
documented prior to the participant’s arrival, if those conditions adversely interfere with
normal operations.
REFUNDS: There will be no deduction or return of fees for participants sent
home for behavioral problems or for late arrivals or early departures. It is the
responsibility of the participant’s family to pay for all costs incurred due to late arrival or
early departure regardless of the reason, unless otherwise agreed to in writing. No
refund is available for discontinuation of the camp season due to acts of God, natural
disaster, acts of war or epidemics. In addition, MAMM will consider refunds on a prorated basis if the participant chooses to withdraw from the program on DAY ONE of
the program. After the first day of program, participants forfeit all fees. Refunds when
issued for medical reasons, will be at the discretion of the Director
FEES: All fees must be paid in full at the time of registration. Jurisdiction for the
collection of delinquent funds will be in Cumberland County, Maine, and MAMM is
entitled to recover all costs and fees incurred in the collection of judgment plus 1.5%
per month fee for all late payments. Jurisdiction for all other legal action will be in
Cumberland County, Maine. Any individual bringing legal action against MAMM which
results in a decision in favor of MAMM will be responsible for all related legal, court,
and out of pocket expenses of MAMM, it’s owners' and employees'.
HEALTH FORM: A health form must be on file in our office before a participant
arrives. Please note that this form must be signed by a parent/guardian, allowing a
doctor/hospital to provide emergency care in the event of an accident. If the
participant takes any medications, these must be given to the Director on each arrival
day. This includes over-the-counter or prescription. PLEASE COMPLETE THIS VERY
IMPORTANT DOCUMENT. YOUR REGISTRATION AT MAMM IS INCOMPLETE
UNTIL WE HAVE A COPY OF THE HEALTH FORM.
CELL PHONES: If a camper brings their cellular phone, it will be required that they
will keep them turned OFF while in our program.
VISITING: You may visit the camp sessions if you wish, but please notify our office in
advance. Participants may not leave with anyone other than their own
parent(s)/guardian(s) without prior written permission from you.
MONEY AT CAMP: MAMM will not be responsible for lost or stolen cash at
camp. Your camper should not require spending money while at camp.
EQUIPMENT LOSS/DAMAGE: MAMM provides the majority of equipment needed to
participate in activities, including musical instruments, however, participants should be
encouraged to bring their own preferred instruments/equipment. MAMM will not be
held responsible for loss or damage of personal equipment and belongings brought
with them.
MAMM CODE OF CONDUCT
The following Maine Academy of Modern Music guidelines are designed to
ensure that we maintain a happy, safe, and productive environment for
everyone. Here are the conditions under which we accept participation.
Read them carefully. Refusal to sign this agreement or violation of any of
these policies may subject you to immediate dismissal from participation
without a refund. MAMM reserves the right to dismiss a participant without a
refund for any behavior that is detrimental to the safe and successful running
of the program.
1. The use or possession of alcohol, tobacco, marijuana, or any
other controlled substances or drugs is not permitted at any time,
any location.
2. Sexual harassment or intimidation, whether verbal or physical, is
inappropriate and not permitted or tolerated.
3. Being disrespectful of adults/faculty will not be tolerated.
4. Inappropriate sexual contact is not permitted or tolerated.
5. Hazing or acts of initiation are not tolerated.
6. Verbal or physical displays of racial, sexual, or religious
discrimination are not permitted.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Distribution or possession of lewd, indecent, or offensive
materials or wearing offensive apparel is not permitted. The use
of vulgar or obscene language is not acceptable.
Weapons, fireworks, lighters, matches, and any other incendiaries
are not permitted.
The willful destruction of equipment or property will not be
tolerated and you will be held responsible for repair or
replacement.
Theft of any kind will not be tolerated.
Respect for private property must be observed.
MAMM is not responsible for lost or damaged personal property
(iPods, instruments, cameras, CD's, music players, etc.)
Participants may not leave the facility/property except on
organized MAMM trips or with their parent(s)/guardian(s). To
leave with someone else, participants must have written
permission from parent(s)/guardian(s).
Full attendance is expected during instructional activity and
mealtimes.
Everyone must adhere to rules of facility provided. The MAMM
faculty have authority in each respective area.
ALL MEDICATIONS (prescription or non-prescription) must be
given to the Director upon arrival each day. Medications (including
cough/cold medications) must not be kept in participant’s
possession.
Each member of the program is expected to contribute to keeping
facilities properly cleaned and maintained.
Graffiti and other forms of vandalism are not tolerated.
PARTICIPANT NAME PRINTED:
_____________________________________________________________
PARTICIPANT
SIGNATURE:
_________________________________________________________
DATE ___________________
PARENT’S AUTHORIZATION: THE PERSON HEREIN DESCRIBED HAS
PERMISSION TO ENGAGE IN ALL PRESCRIBED CAMP ACTIVITIES EXCEPT AS
NOTED BY MY PHYSICIAN OR MYSELF. I HEREBY GIVE PERMISSION TO THE
PHYSICIAN SELECTED BY THE DIRECTOR TO ORDER X-RAYS, ROUTINE
TESTS, AND EMERGENCY TREATMENT FOR THE HEALTH OF MY CHILD. IN
THE EVENT I CANNOT BE REACHED IN AN EMERGENCY I HEREBY GIVE
PERMISSION TO THE PHYSICIAN SELECTED BY THE DIRECTOR TO
HOSPITALIZE, SECURE PROPER TREATMENT FOR AND ORDER INJECTIONS
AND/OR ANESTHESIA AND/OR SURGERY FOR MY CHILD AS NAMED ABOVE. I
HEREBY AGREE THAT MAMM’s (Maine Academy of Modern Music) DIRECTOR
MAY DISPENSE OVER-THE-COUNTER MEDICATIONS WHERE DEEMED
NECESSARY. I HEREBY RELEASE THE USE OF PHOTO/VIDEO IMAGES AND
WORK PRODUCT OF THE ABOVE REGISTERED PARTICIPANT FOR THE
PURPOSE OF PROMOTION AND DISPLAY TO THE GENERAL PUBLIC. I HAVE
READ THE POLICIES WRITTEN INCLUDING THE CODE OF CONDUCT, AND
AGREE TO ALL TERMS.
PARENT SIGNATURE
X ___________________________________________________________________
DATE ____________________
Please note that all registrations must also include
MAMM’s HEALTH FORM for each participant.
Please contact us for your copy.
Your audience is waiting. It’s
time to rock.
3
Parent Health Form and Authorization for Treatment
These forms should be read and signed by a parent/guardian
where indicated. Health forms are valid for ONE year only
and MAMM should be notified if any changes to patient’s condition
occur between the time of form completion and arrival for the program.
Name of Program _________________________________________________
Date(s) attending_________________________________________________
First Name___________________________________ Last Name______________________________________
Address_____________________________________ City___________________ State_______ Zip__________
Daytime Phone__(_____)_______________________ Evening Phone__(_____)__________________________
In Case of Emergency Notify_____________________ Relationship___________ Phone__(_____)______ _____
Address_____________________________________ City___________________ State_______ Zip_________
Attention Parents: MAMM is a unique learning situation where individual expression and teamwork go hand in hand. In order to
help your child get the most out of their time at MAMM, we ask that you provide us with personal information regarding any learning,
behavior or personal difficulties they may have. Please include this on a separate piece of paper and attach it to the health form. Any
information you provide will be kept in confidence and will only be used to help provide a healthy learning environment for your child.
If we are not aware of your child’s needs, we cannot help. With your help, we can make this program one of the most enjoyable
educational experiences that your child will ever have.
Please list any medications being taken by your child on a regular basis including non-prescription drugs. Make sure that the child
arrives at MAMM each day with the exact amount of medication needed for that day. Keep all medications in their original
packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and
frequency of administration. All medications must be given to the Director when the child arrives each morning.
MY CHILD TAKES NO MEDICATIONS ON ROUTINE BASIS ________
My child takes the following medication(s). Attach an additional piece of paper if more space is needed:
Medication______________________________ Dosage_____________ Specific time(s) of day___________________________
Reason for medication_______________________________________________________________________________________
Name of family physician _________________________________________________Phone______________________________
Name of family dentist/orthodontist__________________________________________Phone_____________________________
This health form is correct to the best of my knowledge, and the person named above has permission to participate in all activities
except as noted. If I cannot be reached in an emergency, I hereby give permission to the physician selected by the director to
hospitalize, secure proper treatment for, order injection for, or anesthesia for surgery for the person named above. In addition, I have
read and understand the MAMM’s policy above, regarding prescriptions, and agree to the MAMM policies.
Parent/Guardian Signature_______________________________________________ Date_______________________________
Attention: All medications must be administered through the MAMM Director.
To complete your participant’s registration please send completed health form and
photocopy of health insurance card to:
MAMM PO Box 6606, Portland, Maine 04103