Please complete and submit this form to register for the selected summer camp.

Registering for , // - //

  • Does your child have musical experience?

  • Parent 1

    Name *

    Email *

    Alternate Email:

    Telephone *

    Alternate Telephone:

    Address *

    City *

    State *

    Zipcode *

    Confirm First Email Address *

  • Emergency Contact 1

    Name *


    Telephone *

    Alternate Telephone:

  • Medical Information

    The information below is kept confidential. Please list any and all issues, no matter how minor. For allergies, please be specific as to the nature of the allergy (e.g., topical, ingestion) and severity. Please describe any behaviors that will help us create the best learning environment for your child, as well as the group. Note: If medicines are to be given to child during camp, a Medication Authorization Form must be completed by parent or guardian.

  • Authorized Adult 1



    Alternate Telephone:


    Please keep a copy for your records.

    Cancellation Policy

    If a cancellation is made in writing at least 2 weeks (14 days) prior to the start of the program then 100% of program fees will be refunded, minus the non-refundable deposit. If a cancellation is made within one week (7 days) prior to the first day of camp, 50% of program fees will be refunded, minus the non-refundable deposit. No refunds will be made after camps have begun.

    Reporting Illnesses & Absences Due to Illness

    The Eugene Piano Academy should be notified by phone or email if a child is ill, especially if the illness is communicable. Illnesses are kept track of and parents are notified of any communicable disease that children may have been exposed to while respecting the confidentiality of campers and families involved. Campers who have communicable diseases will be sent home and may not return to camp until the illness has been treated successfully and the camper is symptom-free.


    Campers who have signs of head lice (itching, head irritation, etc.) will be removed from their group and escorted to the camp office by the Safety Specialist. If we believe there is a possibility of head lice, we will ask the family to pick their camper up from camp. In order to return to camp, a camper must have had all active lice removed from his or her hair & and no longer show any signs of infestation, itching or irritation.

    Discipline Policy

    Eugene Piano Academy staff uses the positive techniques of guidance, including logical or natural consequences applied in problem situations, redirection of children to more acceptable behavior, anticipation and elimination of potential problems and encouragement of appropriate behavior rather than comparison, competition or criticism. Consistent and clear rules are established. Staff members encourage children to solve problems rather than imposing solutions and help children to recognize and respect one another’s feelings. Counselors encourage pro-social behavior such as cooperation, helping, taking turns and constructive verbal communication to solve problems. The goal is to help children internalize rules and become self-directed in their behavior.

    Eugene Piano Academy reserves the right to dismiss a child for consistent behavior that makes it difficult or impossible for the staff to meet his/her needs and/or the needs of other children in the group. This will occur without a refund (or portion thereof) or credit towards a future program. This will occur only after the first warning and a parent/staff discussion has occurred.

    Toilet-Training Policy

    All campers attending Eugene Piano Academy Summer Camps are expected to be fully toilet-trained by their first day of camp. If a camper has a history of bathroom accidents then we ask that families provide an extra set of clothes each day. If an accident occurs during camp hours, the camp counselor will notify the camper’s primary parent/guardian.

    Medical Consent and Release

    I understand that my child will not be released from the program site unless signed out by a parent/guardian, or designee that is listed above. The Academy will do its best to ensure a safe experience, however, I understand that certain mishaps or accidents may occur. In the event of an injury or medical emergency, I hereby give consent to the Eugene Piano Academy, LLC to provide or arrange for all necessary and appropriate medical and/or dental treatment as prescribed by qualified medical personnel.

    Photographic and Video Release

    My signature irrevocably grants the Academy to use photographs and/or video of all programs for promotional purposes. Child’s first name may appear in printed publications. Denial of this agreement must be submitted in writing, prior to the first camp/day attended.


    I, the Parent or Guardian, expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Oregon and that this Release shall be governed by and interpreted in accordance with the laws of the State of Oregon. I, the Parent or Guardian, also agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provision of the Release which shall continue to be enforceable.

    Parent/Guardian Authorization and Agreement

    As the parent, legal guardian, or agency representative of the child named above, I hereby give consent to enroll my child in the specified program operated by the Eugene Piano Academy, LLC. I recognize that my child must follow safety instructions, remain in areas designated by the instructor and assistants, and refrain from behavior that is harmful to him/herself or others. Failure to adhere to the Academy’s policies will result in dismissal from the program, without refund of fees. I will assume the financial responsibility of repairing or replacing any and all equipment and/or instruments that become damaged due to my child’s negligence. I have thoroughly read all of the registration information and understand it completely, including the above Parent Authorization and Releases. I have informed the Academy of my child’s special needs and considerations. All of the information given is accurate and true to the best of my knowledge.

    By typing your name on the signature line you agree to the above terms.