Registration Form – RockStar101

RockStar's Name*

Date of Birth*

Age*

MaleFemale

Email Address*

Address*

City*

State*

Zip Code*

Guardian's Name

Relationship with child

Home Phone Number

Work Phone Number

Cell Phone Number

Guardian's Name

Relationship with child

Home Phone Number

Work Phone Number

Cell Phone Number

Emergency Contact Name

Contact Number

How did you hear about RockStar 101?

Which Camp/Enrichment Site will your RockStar be attending

List any allergies, medical conditions, or special needs we need to be concerned with.

Is there anything going on in your child's life that we, RockStar 101 need to be sensitive to and you would like to share with us?

Release, Waiver, Financial Responsibility and Authorization

As a Parent or Guardian of my Enrolled Camper(s):

I agree to pay RockStar 101 LLC in full for all services requested.
I agree to allow RockStar 101 LLC to use my/our camper(s)’ photograph, image, likeness, and/or voice in camp publications, promotional materials, website, DVDs, videos, CD or other mediums, without compensation and without prior notice. I/we release and hold RockStar 101 LLC harmless from any liability stemming from such use.
I agree that I will be responsible for any loss, damage or destruction by my camper to any property of RockStar 101 LLC or to any property for which RockStar 101 LLC is liable or chargeable.
I am aware that RockStar 101 LLC may unilaterally dismiss or suspend a camper or deny a camper’s participation in any activity, should it determine that the conduct or behavior of the camper, parent/guardian, or other family member is deemed unsatisfactory and/or not in the best interest of RockStar 101 LLC. NO REFUND will be issued in the event of such dismissal.
I understand that reasonable precautions are taken to ensure that the programs and activities, at RockStar 101 LLC, are conducted by qualiﬁed personnel, in a safe and responsible manner. However, I further understand that because of the nature of some activities within the camp program, there is a possibility of personal or bodily injury, serious injury, disability, and death. These activities include (but are NOT limited to) playgrounds and swimming. I understand that some activities will include activities and ﬁeld trips off the premises.
I: (1) recognize and understand these risks; (2) understand that these risks can be a consequences of not only my camper(s)’ acts or omissions, but also the actions or negligence of RockStar 101 LLC (including staff, employees, volunteers, or any other of the Released Parties as deﬁned below), other participating campers, independent contractors or third parties, or transportation and equipment; and (3) agree to allow my camper(s) to participate in the programs and activities, including those off premises.
I agree individually, and on the behalf of my camper(s) to assume full, sole, and complete responsibility for ALL RISKS, inherent and otherwise, known and unknown, whether or not they have been described to me, and waive, release and discharge, and covenant not to sue, RockStar 101 LLC each of their ofﬁcers, employees, directors, agents, insurers, and volunteers and their successors and assigns (Collectively the “Released Parties”) from any and all liability and/or claims, suits, damages, injury, disability, death, costs and expenses, whether arising before, during or after participation in camp activities (including any motor vehicle transportation, morning care, afternoon care, or administration of medicines/treatment) and whether caused by the sole or joint negligence, gross negligence, or tortuous act or omission of the Released Parties, or any of them, or any third party (Collectively the “Claims”). This Waiver and Release does not apply to the willful misconduct of the Released Parties. The Releasors hereby knowingly and voluntarily waive, to the fullest extent permitted by law, the beneﬁts of any statue, law, rule or common law, which may limit the scope of this Waiver and Release.
I release and hold harmless RockStar 101 LLC its ofﬁcers, directors, employees, and agents from any responsibility or liability for any lost, stolen, or damaged personal property which my camper(s) brings to camp.
If I cannot be reached, I hereby give permission for emergency medical treatment, emergency transportation, hospitalization, anesthesia, x-ray or necessary injections for my camper(s), and will be responsible for the bills of same. This authorization does not include major surgery, unless life-threatening, and only then when the medical opinions of two (2) licensed physicians or dentists concur in that treatment.

Refund Policy

As a Parent or Guardian of my Enrolled Camper(s):
I understand and agree that once camper(s) is/are enrolled, that there will be absolutely no refunds of tuition paid unless Parent cancels this contract in strict accordance with the cancellation procedures, as follows:

Parent must submit a letter/email of cancellation so that it is received by the Camp Director no later than the day before ﬁrst day of camp.
In the event of timely cancellation, Parent will receive refund of all amounts paid in excess of the Non- Refundable, Non-Transferable deposits/processing fees which are $80.00 per camper.
After the day before the ﬁrst day of camp, there will be absolutely No Refunds of any amounts for any circumstances, including, but not limited to, extended illness, family emergency, hurricane/tropical storm watch/warning closures, expulsion, or withdrawal.
In addition, in the event of closure for hurricane/tropical storm watch/warning, RockStar 101 LLC will close for the duration of the watch/warning and will not issue make-up days.

Is there anyone who is NOT allowed to pick up your camper(s) as per a court order?

If Yes, Please List

Are there any legal custodial issues that we should be aware of?

If Yes, Please attach documents with details

I have read the above Release, Waiver, Financial Responsibility and Authorization Statement/Refund Policy and agree to abide with the terms stated.