Application
Victor Manuel Gomez Music Foundation
1537 West 46th Street, Los Angeles CA. 90062
Registration Application
PIANO, VOICE, GUITAR, VIOLIN ,RECORDER, CLARINET ,DRUM, ETC.
School:_____________________________________
Student Name:____________________________
DOB: ____________________________
Grade:_________________________________
Teacher / Room #________________________________________
Student’s Address:________________________________________
Mother’s Name:__________________________________________
Mother’s Phone:_________________________________________
Father’s Name:_________________________________________
Father’s Phone:__________________________________________
Emergency Phone:___________________________________________
Liability Release Form
I understand that participation in the program / activity could include actions or tasks, which might be hazardous to the participant name above. By signing below, I assume any risk of harm or injury , which might occur to the participant due to his/ her/ fall my participation in the event or activity. I release the organization or business name above from all liability , cost and damages, which might arise from participation in the above name event or activity. If the participant is a minor, I agree that the minor has my consent to participate in the event . I further provide my consent for the organization or business name above to seek emergency treatment for the minor if necessary. I agreed to accept financial responsibility for the costs related to this emergency treatment.
Name of participants: ______________________________________________
Signature of parent or Guardian:___________________________________
Date: __________________________________