Music Therapy Questionnaire

Contact Information

Participant First Name: *

Participant Last Name: *

Age: *

Birth Date: *

Email Address: *

Phone: *

Address: *

City: *

State: *

Zip: *

Mother's Name: *

Phone Number: *

Father's Name: *

Phone Number: *

Special Needs Questionnaire

What kind of special education services does your child receive at school?

Does your child participate in any other special education programs?

What is your child's exceptionality? Please submit any special condition and symptoms of your child that we neeed to be aware of:

What are some special talents or favorite activities for your child?

Does your child have any strong dislikes?

Has your child had any previous musical experiences, preferences, likes or dislikes?

Is your child able to perform basic motor skills such as walking, clapping, talking, etc?

Does your child use a wheelchair?

Release of Photo Waiver

In consideration for being permitted to utilize the facilities, services, and programs of the YMCA for any purpose, including but not limited to observation or use of facilities or equipment, or participation in any program affiliated with the YMCA, without respect to location, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated programs have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use, or participation. I hereby give permission to have the Athens YMCA use photos and images of the participant in any publication affiliated with the Athens YMCA or with any news service for publicity such as program newsletters, fundraising brochures, press releases to local newspapers, and the Athens YMCA’s website. I understand and agree that there will be no compensation for use of these materials. This release shall continue in effect until I send in written notice to terminate the use of any image of participant. Such termination shall not affect the use of images before the notice of termination.

Write "Yes" if you would like to opt out of the photo release.

Waiver of Liability/Indemnity Agreement

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE, INCLUDING BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY PROGRAM AFFILIATED WITH THE YMCA, WITHOUT RESPECT TO LOCATION, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, and agents (hereinafter referred to as "releases") from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releases or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein, or participating in any program affiliated with the YMCA, without respect to location.
THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releases and each of them from any loss, liability, damage, or cost they may incur due to the presence of the undersigned in, upon, or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releases or otherwise.
THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE due to negligence of releases or otherwise while in, about, or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

THE UNDERSIGNED further expressly agrees that the forgoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of GEORGIA and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITYAGREEMENT, and further agrees that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.

I have read this release.

Relationship to Participant:

Signature:

Date:

Verification Code

Reload Image

Music Therapy Questionnaire

Contact Information

Special Needs Questionnaire

Release of Photo Waiver

Waiver of Liability/Indemnity Agreement

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