Student's Name *

First Name

Last Name

Parent's Name *

First Name

Last Name

Teacher's Name *

First Name

Last Name

Primary Contact Phone Number *

Phone number of the person filling out this form

(###)

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Waiver of Liability *

In consideration of the risk of injury while participating in this Hawaii Music Teachers Association Program (the "Activity"), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge Hawaii Music Teachers Association, located at PO Box 4485, Honolulu, HI 96812, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity. I am voluntarily participating in the aforementioned Activity and I am participating in the Activity entirely at my own risk. I am aware of the risks associated with traveling to and from as well as participating in this Activity. I understand that these injuries or outcomes may arise from my own or others' negligence, conditions related to travel, or the condition of the Activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this Activity, including travel to, from and during this Activity. I, the participant (or legal guardian of the participant), affirm that, by checking "I accept" below, I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract that I agree to of my own free will.

I Accept

Photo Release *

I hereby grant the Hawaii Music Teachers Association permission to the rights of my image (or the image of my child), likeness, sound of my voice, and instrumental performance as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears.

I Accept

I Decline