MFC Rock Star - Northeast Iowa School of Music

MFC
Rock
Star
GUITAR LESSONS FOR YOUTH & TEENS!
9 Week Program: September 8th-November 6th
Youth (ages 8-12): Mondays & Wednesdays 3:30-4:15pm
Teens (ages 13-17): Mondays 4:15-5pm & Thursdays 3:30-4:15pm
We have all dreamed of being a Rock Star, now is your chance to get started! In partnership with the Northeast
Iowa School of Music (NISOM), MFC Rock Star will teach youth & teens the basics of guitar and give them the tools
to begin living their dream as a Rock Star! The program will teach kids basic guitar know-how, guitar chords, major
and minor scales, strumming patterns and classic guitar songs. Instructor: Professional guitar instructor Bill Encke,
with local musicians Christian Theisen and Tyler Munn. Already have a guitar? Great. If not, one will be provided
for you during lessons thanks to Uncle Ike’s Music & Sound. This program is sponsored by Dubuque Bank & Trust.
Class size limited. Registration required.*
Multicultural Family Center | 1157 Central Ave | Dubuque, IA 52001 | (563) 582-3681 | www.mfcdbq.org | info@mfcdbq.org
*Register online at www.cityofdubuque.org/recreation If you’re unable to register online, bring the completed
registration form (the bottom part of this paper) to the MFC. Registration forms can also be emailed to

info@mfcdbq.org. Participants will be asked to complete a general MFC registration and release form as well.
Multicultural Family Center Rock Star registration– Fall 2014
Check one:
Youth guitar (ages 8-12)
Teen guitar (ages 13-17)
Participant’s Name:______________________________________________________________
Parent/guardian’s name:__________________________________________________________
Phone:______________________________________ Age:_____________________________
Address:______________________________________________________________________
Parent’s email:_________________________________________________________________
Cost: $5.00 Checks payable to: Leisure Services Department
Youth Registration AND RELEASE Form
Youth Name____________________________________Birthdate______________________________
School
Parent(s)/Guardian(s) _________________________________________________________________
Address______________________________________________________________________________
Phone Number__________________________ Alt. Phone Number______________________________
Parents’ Email
Race (check all that apply):
Caucasian
Pacific Islander/Marshallese
African American
Other, please specify: __________________________
Hispanic
Prefer not to answer
Food allergies or other medical conditions MFC staff should be aware of:__________________________
_____________________________________________________________________________________
Program Attending:_____________________________________________________________________
Parent/Guardian Section
I,
tion of my child,
tural Family Center (“MFC”).
, acknowledge that I have consented to the attendance and participa(“Participant”), in activities at, or sponsored by, the Multicul-
1. Release, Waiver and Hold Harmless. In consideration of the opportunity afforded Participant to attend and participate in activities at, or sponsored by, the MFC, I will not make a claim against the MFC, the City of Dubuque, sponsors or any of their affiliated organizations, or any of their officers or directors collectively or individually, or the supplier of any materials or equipment that
is used by the MFC, or any of the volunteer workers, for the injury or death to participants or damage to my property, however
caused, arising from the participants attendance at and participation in activities at the MFC. Without limiting the generality of the
foregoing, I hereby waive and release any rights, actions, or causes of action resulting from personal injury or death to participant
or damage to my property, sustained in connection with participation in activities at, or sponsored by the MFC. In the event any
suit is brought, I agree for myself, participant, executors, administrators, heirs and assigns to defend, indemnify and hold harmless
the MFC, City of Dubuque, and sponsors, any of their affiliated organizations, or any of their officers or directors collectively or individually, or the supplier of any materials or equipment that is used by the MFC, or any of the volunteer workers, from any and all
liability for any sums or damages
PLEASE TURN OVER AND SIGN!
personally or to property whether such claims are brought in equity or at law which might arise out of participants participation in
activities at, or sponsored by, the MFC including, but not limited to, death or injury, including attorneys’ fees, costs and expenses.
THIS RELEASE AND HOLD HARMLESS TO THE MFC, CITY OF DUBUQUE, SPONSORS AND OTHERS RELATES TO ALL CLAIMS BASED
UPON ACTS AND ALLEGED FAILURES TO ACT, INCLUDING CLAIMS BASED UPON THE NEGLIGENCE OF THE MFC, CITY OF DUBUQUE, AND SPONSORS.
2. Medical Treatment. I hereby consent to the administration of first aid and other medical treatment to participant in the event
of an injury and agree to pay the costs of any such medical expenses. I hereby release and forever discharge the MFC, City of
Dubuque, its leaders and sponsors from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment or service rendered in connection with participants activities with the MFC.
3. Assumption of Risk. I understand that some of the activities mentioned above may be hazardous. I hereby expressly and specifically assume the risk of injury or harm in the activities and release the MFC, City of Dubuque, and sponsors from all liability, illness, death, or property damage resulting from the activities.
4. Insurance. I understand that neither I, nor participant will be covered by any medical, health, accident, disability or other insurance coverage provided by the MFC, City of Dubuque, or sponsors and that participant will not be eligible for any workers compensation benefits.
5. Photographic Release. I hereby consent to the unrestricted use by the MFC, City of Dubuque, or sponsors and/or persons authorized by them, of any photographs, recordings, interviews, videotapes, motion pictures or similar visual recording of participant.
6. Other. I understand that participant will not be paid for services. In all activities I understand that participant shares in the
responsibility for participants own safety and for the safety of the group.
I hereby state that I have read this agreement carefully before signing, I am of legal age, I am the parent and/or legal
guardian of participant, I sign this waiver as my own free act and deed and I understand what it means and what I am agreeing to
by signing.
Signed this _____ day of ____________________, 20___.
*Parent/Guardian Signature
Phone Number
Participant’s Signature
*The MFC will call you to confirm that this is your signature if the signing of the registration form is not witnessed by MFC staff.