TMI-KOC Consent Form

Parent/Guardian Preferred Phone Contact Number:

Student Name:*

Parent/Guardian Name:*

Student Birth Date*

Age:*

Student Home Address: (Street)*

City:*

State:*

Zip:*

Parent/Guardian Preferred Phone Contact Number:*

Valid Parent/Guardian Email:*

EMERGENCY CONTACT INFORMATION -Alternate person to contact in the event of an emergency (two required)

Name of Alternate Emergency Contact:*

Alternate Emergency Contact Daytime Phone:*

Relationship*

Name of Alternate Emergency Contact:*

Alternate Emergency Contact Daytime Phone:*

Relationship:*

HEALTH INFORMATION FOR THE STUDENT

Name of Physician or HMO*

Physician Phone Number*

Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?*

Yes No

If yes, please explain:

Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's TMI class experience is positive? (see Policies and Procedures for accommodation information) :

Yes No

If yes, please explain:

SCHOOL INFORMATION

Is your student currently enrolled in a public or private school in the U.S.?:*

Yes No

If yes above, full name of school attended (2019-2020):

2019-20 Grade:*

School Address:*

City:*

State:*

Zip:*

For students who currently reside within the United States, a United States territory, or the District of Columbia: Does the student have any immunization exemptions because of a parental or guardian objection or medical contraindication:

Yes No

If yes, list them:

For students who reside outside the United States, a United States territory, or the District of Columbia: Attach or submit a record of vaccination or immunity in English on Department form MDH-896.

Student Name (please type student's name):

PARENTAL CONSENT/RESPONSIBILITIES Please check box to indicate that you have read these policies.

I am the parent/legal guardian of the child named above. I have read the Music Institute policies and procedures and agree to the following:* I/We will abide by the policies and procedures of Howard Community College and The Music Institute.:*

Policies and procedures (pages 35-36, KOC Catalog) are subject to change. Refer to the Music Institute webpage (howardcc.edu/tmi) for the most up to date information.

I authorize the release of my child's grade level and directory information to Howard Community College. This information is needed to verify either past or current enrollment in honors, gifted and talented, advanced placement, accelerated courses, or above grade level classes. This information will be submitted to the Maryland Higher Education Commission along with other enrollment data.

I take responsibility for my child's compliance with appropriate student behavior. I understand that disruptive and inappropriate behavior will not be tolerated and will result in non-refundable dismissal.

I/We understand and voluntarily assume all risks inherent in the nature of this activity and I/We waive and release all claims, costs, liabilities, expenses and judgements against Howard Community College and release HCC and its representatives arising out of my child's participation in the activity at The Music Institute. HCC and TMI are not responsible for personal items brought or left on campus. Electronic devices and cell phones may not be used during class hours without instructor permission.

I take financial responsibility for my child's tuition and fee payment to HCC. I certify that I am registering a student for a Music Institute course and that the student has resided at the provided address with a parent or legal guardian for at least three months.

I certify the information provided on registration and consent forms for the child named above is true and correct to the best of my knowledge. I understand that it is my responsibility to notify the Records Office of any change in contact information. Submit change of information form to the Division of Continuing Education and Workforce Development.

Media Release I hereby give my permission and consent for Howard Community College ("the College") and its representatives to use my child's name, likeness, biography, voice, performance, written documents, or other content for purposes related to the mission of the College. The purposes include, but are not limited to, promoting, marketing, advertising, and communicating about the College and any programs or services through websites, social media, television, or other communication channels.

DISMISSAL ARRANGEMENTS - My child will be supervised after class according to The Music Institute (TMI) dismissal policies unless the box below is checked.

Other Dismissal Arrangements I take responsibility and give permission for my child to leave campus unaccompanied (bike, walk, bus, etc.) at dismissal.

THIS FORM MUST BE SIGNED AND DATED TO BE OFFICIAL IN ORDER FOR STUDENT TO BE REGISTERED

Parent or Legal Guardian Signature:(Please type your full name)*

Date:*

Questions? Call 443-518-4297 or email tmi@howardcc.edu.

Important College and Coronavirus Information ››

The Music Institute Consent Form 2020

* = Required Information