EATINIYC

Registration Form
PARTICIPANT INFORMATION , ,
Student's Name Jc:::tci.O"Vl k..a..nSl-ilMl~arent's Name fY1ct,.b lQ___ /Vlu.Jo~
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Date of Birth
Permanent Address '3J+1:L 3 \,0 l ct:-h CV\:"
Email
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City, State, Zip {2J Y<Jl1'X:.., J..J \ 0 J..J f;7 g-~
Name of the school the child currently attends PS \GS 1ft-e, '2....ober-1- Z.,, S 1
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Please check the ethnicity that best describes the child (For statistical purposes ONLY)
Latino/Latina African-American Asian Pacific Islander
Caucasian/White Other (please spec,., _ _ _ _ _ _ _ _ _ _ _ _--/
Does your child qualify for the free or reduced school lunch program? (For statistical purposes ONLY)

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languages :~e spoken at home? __ - _l,l..r.:>
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Does your child have special circumstances or needs of which we should be aware?
Yes @
If Yes, please describe:

How did you learn about UpBeat NYC? _

· ·~bec:U;:; t,(2.0-cUi/
_:~::::=L---------=---------------

Has your child ever received music lessons? Yes

If you answered yes, please answer the next three questions:
Which instrument(s)? ,._;-/ A
For how long? /J I r>c
Group Lessons Private Lessons
Does the child have his/her own instrument? (If not, we will provide one, on loan)
Yes {Nv

MEDICAL EMERGENCY CONTACT INFORMATION

Person to contact First "'1 .• L."' 1t1..}?:'3 Backup Contact (Relative or Friend} .
Name m ob G[ , , , l,l,C-J~
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Name O u. ClJ:j
Relation to Participant
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Relation to Participant 01 CJ~~~'-----==-
Daytime Phone GJ-1: 6 - <:",3£5' -Jf9"t?-G Daytime Phone q I 3:: - 9 H I - 8'"2.38
• Ph Evening Phone
Evening one -;;: _
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HEAL TH INFORMATION
Please list any medical conditions/health issues/allergies:
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Is your child currently on any prescribed or over-the counter medication? (lfso, please record the condition/ailment, name of
medication, dosage , time(s) of day, prescribing physician.) AI k::> \.,l.be..(aj £(J"r ctGt hm C\ .

TO BE READ AND SIGNED BY PARTICIPANT

BEHAVIOR EXPECTATIONS OF THE PARTICIPANT

It is important to follow the directions of the adult leader(s) at all times. I understand that as a participant I have the responsibility to
help make the activity a safe experience for everyone through my behavior and conduct. I also understand the danger of not following
rules and d ~ r ~ agree to follow them. C) ::;.- I ·-;)._ I J-~ "2_
Participant S i g n a ~ Date

TO BE READ AND SIGNED BY PARENT OR GUARDIAN

I understand that my child must be healthy and reasonably fit in order to safely participate in UpBeat NYC activities and that I will inform
the program leader(s) of any medication, ailment, condition, or injury that may affect his/her ability to participate safely.

MEDICAL EMERGENCY PARENTAL PERMISSION*

The health history for my child is correct and complete to my knowledge. If an injury or other medical condition occurs or arises, I
hereby give permission to UpBeat NYC staff or volunteers to provide routine health care and seek emergency treatment including x-
rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing or insurance purposes. I understand
that I am financially responsible for charges and hereby guarantee full payment to the attending physicians or health care unit. In the
event of an emergency where I cannot decide for my child, I give permission to the physician/hospital selected by the UpBeat NYC staff
or volunteer to secure and administer treatment for my child, including hospitalization.

fr\()') initial () rl 2. ti /;;-

PUBLICITY/IMAGENOICE PERMISSION
UpBeat NYC normally takes photographs, video, and/or tape recording of our programs. During activities, a photograph or video/audio
recording may be taken of you or your child. Unless you request otherwise, your initial below will be considered permission for Up Beat
NYC to photograph, film, audio/video tape, record and/or televise your image and/or voice or the image and/or voice of your child for
use in any publications 01
promotional materials, in any medium now known or developed in the future without any restrictions.
Y'{\ Y\1 initial 0:t ['2.J /dat~ '.l.
TRANSPORTATION
I am giving my permission for my child to be transported during an authorized activity or event. I give my permission for my child to ride
with any adult volunteer driver (including UpBeat NYC staff).

I understand that if personally-owned vehicles are used as transportation to and from UpBeat NYC events or activities, that the owner
of the vehicle is responsible for any liability that might occur during the transportation. UpBeat NYC does not provide coverage for
any property damage, personal injury or liability that may occur while using personal vehicles.
(YI m initial O-rhtb.._1t11e
ASSUMPTION OF RISK AND REl,..EASE OF LIABILI~ (P/e'dse read carefully.)
I give permission for :::J'01.0l 01'\ VcV'lE;, I 01 I CJ},o participate in the Up Beat NYC program. I understand that UpBeat
NYC project activities/events may involve certain risks of physical activity and possible injury and that UpBeat NYC will provide each
participant with reasonable care, but that UpBeat NYC cannot guarantee that my child will remain free of injury. I nonetheless wish to
have my child participate in the UpBeat NYC program and ASSUME the RISK of participating. I agree to RELEASE from LIABILITY,
INDEMNIFY and HOLD HARMLESS UpBeat NYC and their officers, employees and agents (hereinafter the RELEASEES) from any
and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other
expenses or liabilities that occur as a result of my child's participation in the UpBeat NYC program. This release, however, is not
intended to release the above-mentioned RELEASEES from liability arising out of their sole negligence.

01/:i1 Date
1~2-
(Must be signed by the parent or guardian if the participant is under 18 years old)

UPBEAT NYC DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, GENDER, RELIGION, NATIONAL ORIGIN, OR
ETHNICITY IN STUDENT ADMISSIONS OR IN ANY PROGRAMS IT ADMINISTERS.