MOYER MUSIC STUDIO

(Please complete one form per child)

STUDENT MEDICAL INFORMATION

Student Name________________________

List Allergies/Special Needs_____________

Parent Name______________________________________________

Medical Insurance Company___________________________________

Policy Number________________________

Clinic/Doctor's Name________________________________________

Clinic/Doctore' Name________________________________________

STUDENT PERMISSION FORM

I give permission for my child,__________________________,to participate in classes and activities with Moyer Music Studio under the supervision and direction of Mrs. Moyer. I release Moyer Music Studio from any liabliliy for any personal injuries to students, caregivers, and/or observers or property damage/loss while attending, coming to, or leaving from any studio class or activity. I give permission to the teachers to take whatever steps may be necessary to obtain emergency medical care as warranted.

I understand that it is my responsibility to reseubmit this form if any changes occur regarding the health of my child, and that any expenses incurred in necessary emergency (or other) medical treatment will be paid by the child's medical coverage or the family.

Parent Signature___________________________________________Date____________

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MEDIA RELEASE

I give permissions for my child's and any caregiver's/observer's images to be used in any Moyer Music Studio publications, promotional materials, videos, slide shows, and the Moyer Music Studio website.

Parent Signature___________________________________________Date____________