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2009 Pianofest Application/Medical Release Form Name (Please Print)_________________________________________________________ Sex: M F Address_________________________________ City____________________ State, Zip____________ County___________________ School____________________________ Grade________ Age_______ Home Phone _______________ email_________________ Adult T-Shirt Size: Sm__ Med__ Lg __ XL__ (If currently studying piano) Teacher Name__________________Address_____________________ Phone____________ Please mark the specific camp that you will be attending *Senior Camp_____ *Junior Camp_____ Elementary Day Camp_____ Please mark appropriate group level (consult guidelines on p.2 to determine group level) I____________ II____________ III_____________ IV____________ *Pianofest will not offer chaperoned Resident status this year. However, students who live outside of the Lexington area may stay in University housing or dormitory if accompanied by a parent, guardian, or teacher who will accept responsibility for that camper. Pianofest will not accept responsibility for any resident camper. However, campus housing arrangements may be made by contacting Hank Snead, UK Conference Housing at 859-257-2042 x230. Campus housing information is also available at www.uky.edu/housing/summer_conferences/. All participants must submit completed medical release form and copy of insurance card before being admitted to camp. Please enclose copy of insurance card (front and back) with registration. List any chronic disease or medical problems_____________________________________________________________________________________ List any allergies to medications, food, environment________________________________________________________________________________ List all medications taken on a regular basis and specify the need for each_______________________________________________________________ List all medications that may be taken only as needed_______________________________________________________________________________ Name and Phone of regular physician(s)____________________________________________________________________________________ Any other information that you consider important or helpful_________________________________________________________________________ Parent/Guardian Name_____________________Address_________________________Daytime Phone_____________ Additional Name and Phone in case of emergency______________________________________________________________________________I/We as the parents/guardians of _______________________________do hereby give permission for the above-named child to attend Pianofest 2009 on the University of Kentucky campus. We hereby represent that said child shall be on his/her best behavior during Pianofest 2009 and that said child shall follow all rules and other instructions of Pianofest, Inc., its employees, servants and agents. In the event said child does not follow the rules, or otherwise becomes disruptive, then Pianofest, Inc. shall at the exclusive and sole decision of the executive directors, send said child home during this event without refund of any fees. I/We for and on behalf of said child, hereby release, waive and discharge Pianofest, Inc., its employees, servants and agents, from all liability for any and all loss or damage, and any claim or demands therefore on account of injury to the child or property of the child which may arise out of or be related to any scheduled activity of Pianofest, Inc. The information contained in this application/medical release form is true and accurate to the best of parent/guardian’s knowledge and belief. By signing below, the parent/guardian authorizes the release of this information to medical personnel for emergency situations involving the above named child. In any medical emergency, the parent/guardian hereby authorizes Pianofest, Inc., its employees, servants and agents, to admit, on behalf of the parent/guardian above-named child to a hospital for medical treatment. The parent/guardian hereby assumes responsibility for all costs and fees incurred for such medical treatment, and shall further hold harmless Pianofest, Inc., its employees, servants and agents, from any and all loss, liability, damage, or costs that may be incurred arising out of or related to such medical services. Date_________ Signature of Parent/Guardian__________________________________ Contact Information Fax: 859-266-8195 vicki.mcvay@uky.edu To print the above form with Acrobat click here. If you need a free copy of Acrobat click here.
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