Seattle Jazz Workshop at the University of Washington Jazz Workshop,

June 23 - June 27, 2008 from 10 a.m. - 5:00 p.m.

ACKNOWLEDGEMENT OF RISK AND CONSENT FOR TREATMENT

This form must be received by the first day of the session in which your child is enrolled. If not received or not completed,

your child will be ineligible to participate.

Student Name__________________________Home Phone_________________________

Parent/Guardian Name____________________Day Phone__________________________

Parent/Guardian Name____________________Day Phone__________________________

Address_________________________________________________________________

City, State, Zip Code________________________________________________________

Email____________________________________________________________________

I acknowledge that there are risks inherent in any children's program, including but not limited to injury or death arising from:

children's failure to follow instructions of teachers and supervisors; communicable illness; and independent acts of third parties

not under the control of teachers and supervisors. I acknowledge that all risks cannot be prevented, and assume those beyond

the control of the University staff. In order to minimize risks to my child or other participants, I will take responsibility to see

that my child is properly prepared for all activities and is in good health each day of the session. I understand the hours of Jazz

Workshop are as stated above. In case of medical emergency, I understand that every reasonable attempt will be made to contact

me, my family physician, or the emergency contact named below. However, in the event that I or my named contacts cannot be

reached, I give my permission to the adults in charge of the Jazz Workshop to secure emergency medical treatment for my child.

I agree to pay for any charges for emergency medical treatment that are not covered by my personal health insurance. This

acknowledgement applies to the workshop session indicated above.

Emergency Contact (other than parent/guardian)_____________________Phone____________

Health Insurance Co. & Policy No._______________________________Phone____________

Family Physician______________________________________Phone___________________

For your child's comfort and safety, please indicate any special conditions we may need to know

about (allergies, medical prescriptions, recent injuries or illnesses, etc.; use back of form if necessary):

Parent/Guardian Name (Please Print)_______________________________________________

Parent/Guardian Signature_____________________________________ Date______________