Rafael Lopez

Camp Registration

Camper's First Name:

Camper's Last Name:

Campers Age:

Camper's Primary Instrument & Years of Experience:

Camper's Secondary Instrument & Years of Experience:

Parent/Guardian #1 First Name:

Parent/Guardian 1 Last Name:

Parent/Guardian 1 Phone:

Parent/Guardian 1 Email:

Parent/Guardian 1 Address:

Parent/Guardian #2 First Name:

Parent/Guardian 2 Last Name:

Parent/Guardian 2 Phone:

Parent/Guardian 2 Email

Parent/Guardian 2 Address:

Does your child have any medical issues we should know?:

Is your child allowed to travel home alone after camp?:

Who else is permitted to pick your child up?:

Is anyone forbidden to pick your child up?:

Read the agreement below:

By clicking “I AGREE” below, I acknowledge that I have read, understood, and agreed to the Elite Music Academy Inc. WAIVER AND RELEASE OF LIABILITY: I AGREE The parent/guardian has signed and agreed to the Elite Music Academy's March and/or summer camp program by Elite Music Academy Inc., hereafter “EMA” , WAIVER AND RELEASE OF LIABILITY. A PARENT, LEGAL GUARDIAN OR EMPOWERED REPRESENTATIVE OF EACH MINOR CHILD(REN) REGISTERING TO ATTEND EMA MUST AGREE TO THE TERMS OF THIS WAIVER AND RELEASE OF LIABILITY AND NAME AND LIKENESS PRIOR TO THE CHILD(REN) PARTICIPATING IN THE CAMP. Physical Condition: On behalf of my child(ren), I accept and assume any and all risks associated with his/her/their attendance and participation in the camp program run by EMA and all related activities. I understand that my child(ren) should not attend the Camp if he/she/they are not in a healthy condition. Furthermore, I do hereby verify that my child(ren), to the best of my knowledge, is free from contagious disease, is fully immunized, and is able to participate in . Therefore, I hereby confirm that my child(ren): (i) has no psychiatric, medical, and/or physical condition or history which would prevent him/her from participating in EMA and/or endanger himself/herself/themselves or others at EMA; (ii) has not been instructed by any physician to refrain from participating in EMA; and (iii) is physically fit and able to participate in EMA. Equipment and Facilities Inspection: I understand and agree that my child(ren) must abide by Camp policies and rules and the instructions of the EMA staff and owners at all times, and that my child(ren)’s failure to do so will result in his/her/their immediate dismissal from EMA. Some of these policies and instructions are written and some are at the sole discretion of the Camp directors and staff; however it is understood that all policies, rules and instructions seek at all times to ensure the overall safety of the Camp and each of its participants. Furthermore, should my child(ren) fail to behave in an appropriate manner, intentionally harm another participant, exhibit signs of illness, or otherwise violate the Camp policies and rules, I shall promptly retrieve my child when contacted by EMA to do so, or, if I am unable to do so, notify EMA of the person retrieving my child(ren) on my behalf. I acknowledge and agree that no part of the tuition paid will be refunded to me should my child(ren) be dismissed from the Camp. I also understand and agree that no reduction or prorate in the tuition will be made for late arrival, early departure, vacations, illness, or injury. I agree that before my child(ren) participates in EMA's Camp, I will inspect the various Camp locations and facilities and all equipment to be used in the Camp. I will immediately advise EMA’s instructors or representatives organizing and/or supervising the Camp of any unsafe condition that I observe and will refuse to allow my child to participate in the Camp until all unsafe conditions observed by me have been remedied. Assumption of Risk: I understand that my child(ren) and each participant in the Camp will be engaging in activities that may involve the risk of serious physical injury, illness, permanent disability, dismemberment and death, and that also involve the risk of severe economic and property loss and damage. I understand that these risks may result from the actions, negligence and failure to act of my child(ren) and others (including but not limited to other participants in, and the organizers, employees, staff, counselors, and volunteers, if any, of the Camp) and the conditions of any real or personal property, facilities or equipment used during the Camp. I also understand that there may be risks involved which are not known to me, my child, EMA, or each of its owners, organizers, property owners, landlords, employees, staff, counselors and volunteers, if any, and may not be foreseen or reasonably foreseeable by any of the foregoing entities or persons at this time or at the time of the Camp and any activities in which my child(ren) may participate. I, on behalf of my child(ren), assume all of the foregoing risks including the risk of any negligence by other participants or by EMA and its owners, organizers, property owners, landlords, partners, directors, officers, employees or agents, and the risk of injury caused by the condition of any real or personal property, facilities or equipment used during the Camp, and accept personal responsibility for any injury (including, but not limited to, personal injury, disability, dismemberment and death), illness, damage, loss, claim, liability or expense (including reasonable attorneys’ and professionals’ fees), of any kind or nature, that my child(ren) or I may suffer arising out of or in connection with the Camp or my child’s participation in or attendance at the Camp. For certain programs and for certain children, these risks may include transportation via motorized vehicle (shuttle, car, van, walking, and/or public transit including bus, streetcar, or subway) to and from the Camp and during camp hours. Permission is granted to EMA to transport my child(ren) via motorized vehicle to and from camp and during Camp hours between different segments of the EMA’s locations/facilities and any outside facilities used by EMA during the Camp. I, on behalf of my child(ren) agree to indemnify and hold harmless EMAand its owners, organizers, property owners, landlords, partners, directors, officers, employees or agents from any claim that I might have arising out of my child(ren)’s participation in, transportation by, or involvement with EMA's motor vehicle transportation. I understand that my child(ren) are fully responsible for complying with all rules and regulations of the motorized vehicle service and that EMA reserves the right to cancel my child(ren)’s participation in the motorized vehicle service at any time. I further understand that while EMA will make every effort to minimize lost items on the motorized vehicle, EMA is not responsible for any property left on the motorized vehicle. I also understand that there will be specific and non-negotiable times for the departure and arrival of some of the Camp’s transportation, and EMA has the right to cancel my child(ren)’s participation in the motorized vehicle if these departure and arrival times are not respected. Furthermore, I agree that no general or limited partner, shareholder, director, officer, member, beneficiary, trustee, manager, other controlling person, investor, employee, attorney, agent, property owners, landlord, or independent contractor of EMA shall be personally liable for any obligation or liability of such party in connection with the Camp, and all obligations and liabilities of such party in connection with the Camp are enforceable solely against such party and such party’s assets, and not against any Exculpated Person or the assets of any Exculpated Person. Medical Treatment: In connection with any injury my child(ren) may sustain or illness or other medical conditions my child(ren) may experience during his and/or her participation in or attendance at the Camp, I authorize any emergency first aid, medication, medical treatment or surgery deemed necessary by the attending medical personnel if I am not able to act on my child’s behalf. In the event that I cannot be contacted in the event of an emergency, I further hereby grant EMA permission to administer immediate treatment and/or take my child(ren) to a hospital emergency room via ambulance/emergency vehicle. I further authorize the attending medical personnel to execute on my child(ren)’s behalf any permission forms, consents or other appropriate documents relating to medical attention. I agree to assume all liability for any expenses incurred in such an emergency (transportation, hospitalization, x-rays, etc.). I also understand and agree that EMA will notify me if my child(ren) becomes ill during Camp hours, and I will arrange to have my child(ren) picked up immediately from Camp. Further, I waive and release EMA and its owners, organizers, property owners, landlords, directors, employees, and independent contractors from any and all liability for personal injuries, illness, loss, or damage to property. Name and Likeness Release: In consideration for my child(ren) being permitted to participate in EMA, permission is also hereby granted for photographs and/or videos to be taken of my child at Camp and EMA has the right to utilize my child(ren)’s name, voice, and likeness (including but not limited to photographs and any video/audio recording of my child(ren)’s appearance at EMA) in any and all manner and media, now known or hereafter developed, throughout the universe in perpetuity without limitation and without additional compensation or consideration, notification or permission, unless prohibited by applicable law. I hereby waive any right that I or my child(ren) may have to inspect or approve any finished product (including but not limited to any brochures, videos, slide shows, web sites, and/or other Camp materials) or any advertising copy that may be used in connection therewith or the use to which it is applied. I hereby warrant that I have the right to make this release on behalf of my child(ren) and that my granting this waiver and release and the rights conveyed thereby will not infringe upon the rights of any third party. I hereby assign all right, title and interest my child(ren) or I may have in any and all media now known or hereafter developed in which any or all of my child(ren)’s appearance, name, voice and/or likeness have been captured in connection with EMA, along with full rights of assignability. I understand and agree that any photographs and/or video/audio recordings I make of my child(ren) at EMA shall be used solely for my and his/her/their private, non-commercial use, and that absolutely no sale, transmission, distribution or commercial use of any such photographs and/or video/audio recordings or descriptions are permitted. Liability Release and Indemnity Agreement: I, on behalf of my child(ren), hereby release and forever discharge and agree to indemnify and save and hold harmless EMA, the respective owners (direct and indirect) and affiliated and subsidiary companies, volunteers associated or affiliated with the Camp, and EMA’s respective officials, property owners, landlords, owners, partners, directors, officers, employees and agents, and the other participants in the Camp (each such entity or individual being referred to as a “Released Party”) of and from any and all injuries (including personal injury, disability, dismemberment, and death), illness losses, damages, claims, liabilities or expenses of any kind or nature (and whether accruing to me, my child(ren), my heirs or my personal representatives) that are caused or alleged to be caused in whole or in part by the action, negligence or failure to act by any Released Party or condition of any real or personal property, facilities or equipment of any Released Party and that arise out of or in connection with the Camp or my child’s participation therein or attendance thereat. I acknowledge that, in the event of any breach by EMA or any third party, the damage, if any, caused me or my child(ren) thereby will not be irreparable or otherwise sufficient to entitle me or him/her/they to seek injunctive or other equitable relief, and my child(ren) and I will be strictly limited to the right, if any, to recover damages in an action at law. Neither my child(ren) nor I will have either the right to rescind or terminate this waiver and release or any of EMA’s rights hereunder, or the right to enjoin the production, exhibition, or other exploitation of my child’s name, voice and likeness or any subsidiary or allied rights with respect thereto. Severability of Provisions: I represent that I am the parent and/or legal guardian (or empowered representative of the parent and/or legal guardian) of the minor child(ren) identified in the online registration form with the authority to give this waiver and release, and I hereby agree that both my child(ren) and I shall be bound hereby. I agree that the foregoing terms and conditions are intended to be as broad and inclusive as is permitted by law, and any terms and conditions set forth herein found by a court to be void or unenforceable shall not affect the validity or enforceability of any other terms and conditions. This waiver and release will insure to the benefit of and will be binding upon both my, my child(ren)’s and EMA’s respective affiliates, successors, licensees, assigns, heirs and representatives including EMA and its owners/directors. The validity, construction and enforceability of this waiver and release shall be governed by, and construed and interpreted in accordance with the internal laws of Canada and Ontario without regard to conflict of law rules applied in such provinces. Conclusion: I have carefully read the entirety of this waiver and release and agree to all its terms and conditions. Knowing all of these facts and in consideration for your accepting my child(ren)’s enrollment form/online registration and for being allowed to participate in EMA, I, for myself, my child(ren) attending the Camp, and anyone else who may claim on me or my child(ren)’s behalf (“I”) hereby agree that EMA. and/or the schools or facilities that host the camp program, are responsible for accidents, injuries, and/or medical or dental expenses arising from my child(ren)’s participation at EMA and, accordingly, I covenant not to file suit against or otherwise sue EMA, and waive, release, and discharge EMA and the various schools or facilities that host EMA , and anyone working on their behalf from any and all claims of liability or expenses of any kind or nature whatsoever arising out of or relating to my child(ren)’s participation in the Camp. I have carefully read all of the information in this online enrollment form and agree to all its conditions.

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Piano Instructor ( Classical, Pop, Rock), Music Educator, Concert Pianist

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