*Please Select Camp Session:

*Student Name:

*Student Age (as of May 2016):

*Address:

*Student Contact Number:

*Parent/Guardian Name:

*Parent/Guardian Contact Number:

*Parent/Guardian Email:

*Emergency Contact If Other Than Parent/Guardian:

*Student Shirt Size:

*Known Allergies:

*Any Special Needs or Physical/Health Concerns?

*How did you hear about RLRM Songwriter's Experience?

I understand that as a part of the Songwriters Experience, my student's pictures, or videos of my student's activities may wind up in media outlets including, but not limited to, newspaper, television, Facebook, YouTube, Instagram,etc.

I give permission for my student's photos and videos to be used and I understand that Songwriter's Experience/Real Life Real Music allows students to document the week with their own phones/cameras and do not hold Songwriter's Experience/Real Life Real Music liable for student photo and video activities.

Do you give consent?

YesNo