I hereby confirm that the information that I provided on this form is true and accurate to the
best of my knowledge. I authorize my son/daughter to participate in ZUMIX, Inc. programs and activities. In giving this authorization, I agree that I will not bring suit against ZUMIX, Inc. including any of its officers, employees, contract staff, agents, or sponsoring agencies for any reason including property damage or personal injury incurred by myself or my son’s/daughter’s participation in ZUMIX, Inc. services, programs, or activities. I also authorize ZUMIX, Inc. to take and use photos, and/or audio/video recordings of my son/daughter while he/she is a participant in ZUMIX, Inc. services, programs, or activities.
All songs recorded for projects at ZUMIX will be considered the composition of the student
who wrote them, however ZUMIX shall maintain all rights to the recordings and may use
them to represent, market, and raise funds to support their programs. In addition, ZUMIX shall have the right to use images of my child in conjunction with this project to represent, market, and raise funds to support their programs. Students shall not receive compensation (financial
or otherwise) for their participation in or creative contribution to ZUMIX programs unless it is
part of the program design and the terms have been previously arranged. I understand that
any proceeds derived from sales of these products will be used to support further programs
I have listed any health problems that my child has and that may affect him/her (example: asthma, taking medication twice daily, allergies, or recent injuries). In the event of a sudden serious injury or illness to my son/daughter whiile he/she is participating in ZUMIX, In. services, programs, or activities, I express my consent for the administration of emergency medical care, including anesthesia, if such action is desirable in the opinion of the attending medical
personnel. I shall be responsible for all medical fees and other charges. I understand that the leaders will make a reasonable effort to contact me, should a sudden injury or illness occur.
In signing this application, I certify that my child is covered by health insurance and accident insurance or Medicaid and that I am obligated to provide ZUMIX, Inc. with the name and the carrier and policy number. I understand that if I do not have insurance I shall be responsible for
all medical fees and related charges whether I am insured or uninsured.
My typed name below represents my digital signature.