Registration Questions

Name

Name of Student

First Name

Last Name

Student Email

Phone

**Contact phone # while traveling

(###)

###

####

Address

Student mailing address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Student Age

Preferred Pronoun

Select preferred pronoun for camper

Accomodations

Where will you stay during camp? (If you are staying off-site you must have your own transportation to and from camp every day)

Name (for Billing)

**If different from student name

First Name

Last Name

Address for billing

**only if other than student**

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Instrument

What is your primary instrument?

Years played

How long have you been playing music?

Other Instruments

What other instruments do you play?

Musical Inspirations

Who or what are your musical inspirations and influences?

Previous Vix Camps Attended

Which in person or virtual Vix Camps programs have you attended?

Dietary restrictions

Select all that apply.

None

Vegetarian

Vegan

Gluten Free

Dairy Free

Food Allergies

List any SERIOUS food allergies here.

Other Allergies

List any SERIOUS non dietary allergies here.

Physical or other disability

Do you have any physical or emotional disorder/disability or special needs we should be aware of to better serve you? Please describe. If not applicable enter 'NONE'

Any recent operations or serious injuries?

Have you had any recent operations or injuries and if so, what are they? If not applicable, enter 'NONE'.

Prescription Medications

Are you currently taking prescription medications that we should be aware of in case of medical emergency and if so, what are they? If not applicable, enter 'NONE'

Emergency Contact

Enter name of person to contact in case of emergency

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Email

Enter Email

Relationship

What is the emergency contact's relationship to you?

Vix Camps Release & Authorization - I am fully aware that camping, tracking, survival, awareness and other activities at Victor Wooten’s Center for Music and Nature, even under the safest conditions possible, may be dangerous. I understand and acknowledge that participation in camp activities contains certain risks of physical injury. I also understand that I am not obligated to participate in any of the class activities at VixCamps. Therefore, I knowingly and voluntarily hereby agree to accept full responsibility and to assume fully any and all risks, including, but not limited to, those caused by acts of God, those resulting in injury or death, and/or those resulting in loss to my person and/or property arising from any activity. In the event that I am injured while attending Victor Wooten’s Center for Music and Nature at Wooten Woods and/or any other facility or location at Victor Wooten’s Center for Music and Nature, and require the attention of a medical professional, I consent to any reasonable medical treatment determined necessary by a licensed medical professional or EMT. I further acknowledge that Victor Wooten's Center for Music & Nature cannot, and therefore will not, guarantee that I will not become infected with the Coronavirus/Covid-19 or any other illness. I therefore acknowledge that I am fully and personally responsible for my own safety and actions and I recognize that sharing indoor living spaces and my participation in this program may put me at risk of contracting any illness and or virus, including, but not limited to Covid-19. In case of medical emergency, I hereby give permission to the medical personnel selected by a camp staff member to order X-rays, routine tests, treatment, to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me. I hereby give permission to the medical professionals selected by the camp staff member to secure and administer treatment for me, including hospitalization. In the event that any kind of medical treatment is needed, and with full knowledge of the risks involved, I do agree and hereby hold such persons, Victor Wooten, Victor Wooten’s Center for Music and Nature, Wooten Woods, all staff, board, officers, independent contractors, affiliates, employees, representatives and all volunteers thereof, free and harmless, release, waive, discharge of any liability, claims, demands, or suits for damages arising for anything whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to illness or injury while participating in any activity while in, on, or around the premises. I agree to indemnify, defend, and hold harmless Victor Wooten’s Center for Music and Nature from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from the giving of such consent for treatment administered by or under the supervision of a medical professionals, including, but not limited to, physicians, EMT personnel and therapists. I agree and do hereby release and hold such persons, Victor Wooten, Victor Wooten's Center for Music and Nature, Wooten Woods, all camp staff, representatives, volunteers, board, independent contractors thereof, free and harmless of any and all liability, claims, demands, or suits for damages arising from any situation, including, but not limited to, all actions or liability in connection with any and all activities, illnesses, catering, transportation, or accommodations for the camp. I hereby authorize Victor Wooten's Center for Music and Nature to use any photographs or likeness of me for any promotional purposes.

Please read and accept Release and Authorization

Camper's Initials/E-signature

Initial to accept

Date

Date of E-signature

YYYY

I am over 18 years of age**

(if no, you must have a parent or guardian complete and e-sign the Parental Release form below)

Vix Camps Parental Release Form - I am fully aware that camping, tracking, survival, awareness and other activities at Victor Wooten’s Center for Music and Nature, even under the safest conditions possible, may be dangerous. I understand and acknowledge that my child’s participation in camp activities contains certain risks of physical injury. Therefore, I knowingly and voluntarily hereby agree to accept full responsibility on behalf of my child and to assume fully any and all risks, including, but not limited to, those caused by acts of God, those resulting in injury or death, and/or those resulting in loss to my child and/or property arising from any activity. In the event that my child is injured while attending Victor Wooten’s Center for Music and Nature at Wooten Woods and/or any other facility or location at Victor Wooten’s Center for Music and Nature, and requires the attention of a medical professional, I consent to any reasonable medical treatment determined necessary by a licensed medical professional or EMT. I further acknowledge that Victor Wooten's Center for Music & Nature cannot, and therefore will not, guarantee that my child will not become infected with the Coronavirus/Covid-19 or any other illness. I therefore acknowledge that I am fully and personally responsible for my own safety and actions and I recognize that sharing indoor living spaces and participation in this program may put my child at risk of contracting any illness and or virus, including, but not limited to Covid-19. In case of medical emergency, I hereby give permission to the medical personnel selected by a camp staff member to order X-rays, routine tests, treatment, to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. I hereby give permission to the medical professionals selected by the camp staff member to secure and administer treatment for my child, including hospitalization. In the event that any kind of medical treatment is needed, and with full knowledge of the risks involved, I do agree and hereby hold such persons, Victor Wooten, Victor Wooten’s Center for Music and Nature, Wooten Woods, all staff, board, officers, independent contractors, affiliates, employees, representatives and all volunteers thereof, free and harmless, release, waive, discharge of any liability, claims, demands, or suits for damages arising for anything whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to illness or injury while participating in any activity while in, on, or around the premises. I agree to indemnify, defend, and hold harmless Victor Wooten’s Center for Music and Nature from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from the giving of such consent for treatment administered by or under the supervision of a medical professionals, including, but not limited to, physicians, EMT personnel and therapists. I agree and do hereby release and hold such persons, Victor Wooten, Victor Wooten's Center for Music and Nature, Wooten Woods, all camp staff, representatives, volunteers, board, independent contractors thereof, free and harmless of any and all liability, claims, demands, or suits for damages arising from any situation, including, but not limited to, all actions or liability in connection with any and all activities, illnesses, catering, transportation, or accommodations for the camp. I hereby authorize Victor Wooten's Center for Music and Nature to use any photographs or likeness of me for any promotional purposes.

Please read and accept the Parental Release Form

Name of Parent or Guardian

Type parent or guardian name here to acknowledge

First Name

Last Name

Initials to confirm e-signature of Parent/Guardian

Initial to accept

Text AreaRefund Policy - The deposit is NON-REFUNDABLE. If you have already paid in full and need to cancel, we will issue a refund less the deposit amount up until two weeks prior to your program start date. From two weeks until program start date, all amounts are NON-REFUNDABLE. *

Please read the refund policy and initial below to accept.