Student Information Form

If you would like to print a copy of this form, click here.

Participant Information

Participant's Name (required)

Parent's Email (required)

Participant's Date of Birth (required)

Gender:  Male Female

Mailing Address:

Parent/Guardian Information

1st Parent/Guardian Name:
Home Phone:
Work Phone:
Cell Phone:
Best Contact #:  Home Work Cell

2nd Parent/Guardian Name:
Home Phone:
Work Phone:
Cell Phone:
Best Contact #:  Home Work Cell

Drop-Off / Pick-Up Information

This participant will only be released to the Parent/Guardians listed above and the individuals listed below.

1. Name:
Relationship to Participant:
Daytime Phone:
Evening Phone:
 Check here if person #1 is also an emergency contact (see below)

2. Name:
Relationship to Participant:
Daytime Phone:
Evening Phone:

Emergency Contact Information

List here the 2 required emergency contacts for this participant in the event that Parents/Guardians cannot be reached.

1. Name:
Relationship to Participant:
Daytime Phone:
Alternate Phone:

2. Name:
Relationship to Participant:
Daytime Phone:
Alternate Phone:

I understand that, in registering for lessons/camp/workshop, my child may be involved in physical activities and that, with any physical activity, there is risk of injury. In the event of an emergency, I authorize the physician in the emergency care unit selected by Colour Outside The Lines Music Centre and/or ClickCamp staff to secure proper treatment for the child indicated above.

I also authorize photography and videotaping of the above named participant, or any musical compositions he/she produces as part of enrolling in the program for Colour Outside The Lines Music Centre, and/or Click Camp Workshops, archival documentation purposes and to authorize publication of this material and any artwork produced, in any media, including my website for promotional or educational purposes.
 Yes No

I agree to the above terms and have ensured that all the information given is accurate and up to date and that if there are any changes that it is my responsibility to inform the Colour Outside The Lines Music Centre.
 Yes No