Completed Forms Are Due by Friday, May 27, 2016, along with the $150 fee for the program



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Dear Parents,

This is your registration packet for the 2016 Youth Rocks Summer Music Program at the Woody Guthrie Center. Please return completed forms to:


Woody Guthrie Center

Attn: Becky Hawkes

102 East Brady St.

Tulsa, Ok 74103

918-574-2710
Enrollment:

Completed Forms Are Due by Friday, May 27, 2016, along with the $150 fee for the program.


.



Youth Rocks Summer Music Program Registration Form


Child’s Name:_________________________________ Birthdate:_____________________

Home Address:_________________________________________________________________

Phone:______________________ Shirt Size:___________ Grade:_________________
Parent/Guardian:_______________________________________________________________

Address if different:_____________________________________________________________

Email Address:_________________________________________________________________

Business Name / Address:________________________________________________________

Work Phone:_______________________________

Member Number (if applicable):__________________________________________________

Woody Guthrie Center

102 East Brady St. Tulsa, OK 74103

Tulsa, OK 74103

Youth Rocks Summer Music Program

Authorization & Consent

Child’s Name:_________________________________ Date:__________________


I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, WGC staff may have my child transported to the nearest appropriate medical facility to secure the necessary medical treatment for my child.
Parent Signature:_______________________________
Child’s Physician:_______________________________ Physician’s Phone:_______________
Physician’s Address:_______________________________________________________________________
Health Insurance Provider:______________________________________________________________
Policy:_____________________________________
Please answer the following questions.

Does your child have any allergies:________________________________________________

If yes, please explain (Symptoms, Medication)______________________________________
Parent Signature:________________________________________

Woody Guthrie Center

102 East Brady St. Tulsa, OK 74103

Tulsa, OK 74103



Photo and Image Release Form
In consideration of the furtherance of the purpose, objectives, and work of The Woody Guthrie Center, (I) the undersigned, hereby grant permission to The Woody Guthrie Center and its agents to take photographs and/or video recordings, and/or audio recordings of my child(ren)
______________________________________________________________________________
to use for educational or promotional purposes. My child’s name or personal information is never included with his/her photo without additional written permission.
Signature:_______________________________________ Date:___________________
Address:_______________________________________________________________________
City, State, Zip:__________________________________________________________________

Woody Guthrie Center



102 East Brady St. Tulsa, OK 74103

Tulsa, OK 74103

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