Student Name *

First Name

Last Name

Emergency Phone *

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Would like to participate in the jazz band

For Instrumental Music Academy Students Only (sax, trumpet, trombone, piano, guitar, bass, perc only):

I would like to participate in the jazz band

Required Academy Waivers *

McNEESE STATE UNIVERSITY MEDICAL RELEASE: I agree on behalf of the above named child, his/her heirs and representative to allow my child to participate in the activities of the McNeese State University Summer Band Academy. I do hereby release and discharge McNeese State University and/or McNeese State University Summer Band Academy representatives, agents, servants and employees from any and all damages on account of any injuries or illnesses sustained to or by my child while engaged in such activity at McNeese State University or at the McNeese State University Summer Band Academy, whether related or not to the activity enumerated above. The campus infirmary is not able to provide any type of medical treatment to summer academy students. All medical care will be referred to off-campus treatment facilities. This agreement shall constitute a bar of any recovery by the undersigned individually or brought for and on behalf of the child, and said agreement may be urged and used by McNeese State University as a bar to any recovery by the undersigned or by the child in any suit or claim instituted on account of any injury or illness sustained by my child while engaged in the activities of McNeese State University. HOLD HARMLESS AND INDEMNIFICATION AGREEMENT I release and discharge McNeese State University and/or Band Academy representatives from any and all liability from any and all claims or damages from any accident or illness sustained to or by my child while engaged in the activities the Band Academy. I agree to hold harmless and indemnify McNeese State University and/or the Band Academy representatives against any loss, damages or cost of whatsoever nature including child's heirs, by me, my heirs, successors, or assigns, or by any other person on his/her own behalf or for the benefit of the child. MEDICAL RELEASE FORM AND INDEMNITY AGREEMENT I hereby acknowledge that as a part of the activities of my child attending the McNeese Band Academy, that there is the possibility my child may need to receive medical attention due to injury or accident. I understand that the McNeese Band Academy or its representatives will make a reason able effort to contact me in the event of injury or accident to my child based on the circumstances. In the event that McNeese or Band Academy, or their representatives are not able to contact me, or if the need for medical care appears to be immediate, then I instruct and authorize reasonable and necessary medical treatment for my child. I further agree to release McNeese State University and/or Band Academy and their representatives from any liability for their efforts to secure reasonable and necessary medical treatment for my child as stated above. I, as the parent or legal guardian shall assume full responsibility for all medical bills, including doctor and/or hospital bills incurred by my child. I further agree to reimburse McNeese State University and/or Band Academy and their representatives who may incur expenses in the treatment of an accident or illness of my child. IMAGE RELEASE AGREEMENT: I hereby assign and grant to McNeese State University the right and permission to copyright and/or use and/or publish, and republish, photographic pictures, portraits or video of my child in which he/she may be included in whole or in part, in color or black and white, made through any media by university photographers including the use of any printed matter/video production in conjunction with such photographs/video. I hereby waive my right to inspect and/or approve the finished photograph/video or advertising copy or printed matter that may be used in conjunction with such photographs/video, or to the eventual use that it might be applied. I hereby release and discharge McNeese State University, its assigns, and all persons acting under its permission or authority or those for whom it is acting, from and against any liability as a result of any distortion, blurring, alteration, or optical illusion that may occur in the taking of the picture/video, or processing or reproduction of the finished product.

I hereby accept the terms and conditions stated in the above waivers/agreements.