TMI Summer Enrichment Program Consent Form

Student Contact Information

Last Name*

Full First Name*

Birth Date:*

Age:*

Home Address*

City*

State*

Zip Code*

Preferred phone*

Day

Evening

Cell

Parent/Guardian Email*

Emergency Contacts:

People to contact in case of emergency. Provide parent/guardian information and an alternate emergency contact person.

Parent/Guardian

Name (Parent/Guardian)*

Daytime Phone*

Alternate Emergency Contact

Name (Alternate Emerg. Contact)*

Daytime Phone*

Relationship*

Health Information for the Student

Name of Physician or HMO*

Physician's Phone Number*

Please list student's allergies*

Please list academic, emotional/behavioral, or medical conditions of which staff should be aware:*

Is student exempt from any immunization on medical or religious ground?

Yes No

If student is not enrolled in a public or private school in the U.S., a full immunization record is required before registration is finalized. Please submit a DHMH 896 form to the Kids on Campus Office.

DHMH 896 Form to The Music Institute office.

School Information

My child is currently enrolled in a*

School Attended (2016-2017)*

Grade*

School Address*

City*

State*

Zip Code*

If student is not enrolled in a Maryland public or private school, a full immunization record is required before registration is finalized. Please submit form DHMH 896 to the Kids on Campus office.

DHMH Form 896 to The Music Institute office.

Attendance/Dismissal

I understand and consent to these attendance/dismissal policies. My child:

should be supervised until pickup or late policy applies

can leave campus unaccompanied (walk, ride bike, bus, etc.)

Attendance is taken daily. Parents will be notified of absences using information submitted on consent form. For early dismissals, parents must come to HVPA 160A and sign student out before student will be released from class. At dismissal students will be supervised until picked up or late policy comes into effect. Identification is not routinely required.

Permission to Photograph

Yes, my child has my permission to be photographed, interviewed, or videotaped while attending classes for possible use in marketing.

No, my child does not have my permission to be photographed, interviewed, or videotaped while attending classes for possible use in marketing.

Release of Information to Howard Community College

Please check this box to indicate you have read and agree to the release of information statement below*

I authorize the release of my child’s grade level 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. If further information is needed, please call 443-518-4110.

Medications

I understand and consent to these medication policies*

HCC will not administer any medications to students. If medication must be taken while the student is on campus, the parent/guardian is responsible for coming to campus to administer the medication. Written permission from a physician is required for those students who are able to self-medicate. Call 443-518-4110 for a required form. In an emergency, trained staff will administer epi pens or inhalers provided by students.

Parental Consent Agreement

I understand and consent to the parental consent agreement.*

I approve of my child’s enrollment in The Music Institute’s enrichment program and take responsibility for my child's compliance with appropriate student behavior. DISRUPTIVE AND INAPPROPRIATE BEHAVIOR WILL NOT BE TOLERATED AND WILL RESULT IN NON-REFUNDABLE DISMISSAL.

Waiver of Responsibility

Please check this box to indicate you have read and agree to the waiver of responsibility statement below*

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 judgments against HCC and release HCC and its representatives arising out of my child’s participation in the activity at The Music Institute. HCC and The Music Institute 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. HCC is not responsible for lost, broken, or missing items.

Electronic Signature

Please check this box to certify your electronic signature and agree to the statement below.*

THIS FORM MUST BE SIGNED AND DATED TO BE OFFICIAL IN ORDER FOR STUDENT TO BE REGISTERED. I certify the above information to be 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 the information contained in this application. I will take financial responsibility for my child’s tuition payment to HCC. I certify that I am registering a student for a Music Institute (TMI) course, that the student has resided at the above address WITH A PARENT OR LEGAL GUARDIAN for at least three months, and that the information presented here is correct to the best of my knowledge. THIS CERTIFICATION CONSTITUTES MY ELECTRONIC SIGNATURE.

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TMI Summer Enrichment Program Consent Form