FY25 Chamber Summer Program Enrollment Form

Choose "New" if your child is NOT currently enrolled in a POP music center program, EVEN IF they have attended POP Summer Program before. Choose “Returning” ONLY if your child is currently enrolled in a POP music center program this school year.

The grade your child is currently in (i.e., their grade in Spring of 2025)

I, the undersigned, consent to my child’s participation in Play On, Philly’s (POP) music education program. I agree to hold POP, St. Francis de Sales, Impact Charter School West and any other POP locations harmless against any liability, loss, or expense I incur or suffer as a result of my child’s participation in the program, including but not limited to loss, injury, or expense in traveling to and from program events. I understand that, as with any activity, there are risks to my child. I therefore agree to assume these risks and to hold POP, St. Francis de Sales, Impact Charter School West and any other POP locations harmless from any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to the administration, planning, preparation, development, conduct, and execution of POP. I understand that my student will participate in POP’s music education program from the date of this Agreement until withdrawn.

Children and families who borrow a POP Instrument agree and accept financial responsibility for any damage or loss due to misconduct or negligence of your child’s instrument.

I, the undersigned, will consent to the release of my child’s education records, including my child's IEP and certain health related records, if applicable to POP and its agents and contractors, for educational purposes. Records that may be released include, but are not limited to, Individualized Education Program (IEP) plans, grades, evaluation and re-evaluation reports, and other IEP related documents, diagnostic assessments, medical orders, diagnosis/health conditions, service logs and attendance records. I understand that, except as allowed by law, these records may not be re-disclosed without my authorization. This consent starts at the beginning of the school year and will continue during my child’s participation in POP.

For POP Summer, "leave alone" means that you acknowledge POP staff will not be escorting your child to their mode of transportation going home, whether that means walking outside to your vehicle or traveling to a SEPTA location. I give permission for my child to leave on his/her/their own from Play On Philly at the end of the program each day. If you do not consent to this policy, someone must come inside the building to pick your child up from program.

How will your child be getting to and from program?

I fully understand that only properly licensed and insured commercial carriers provide transportation to and from POP’s sanctioned activities, with POP named as an additional insured. I further understand that POP staff members are not permitted to transport my child in any other vehicle, except in the event of an emergency or with written consent. I authorize POP’s Summer Program Coordinator, or his/her designee, to exercise his/her judgment in determining the existence of a transportation emergency and its safest and most logical resolution. I hereby release and hold harmless POP, St. Francis de Sales, Impact Charter School West, and any other POP locations against any liability, loss, or expense incurred or suffered in consequence of any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, preparation, development, conduct and execution of the POP program.

I, the undersigned, hereby grant to Play On Philly the absolute and irrevocable right and unrestricted permission in respect of photographic portraits, editorial, video or pictures POP had taken of my child or in which they may be included with others, to copyright the same; to re-use, publish and republish the same in whole or in part, individually or in conjunction with other photographs, and in conjunction with any printed matter, in any and all media now or hereafter known, and for any other purpose whatsoever with restriction as to alteration; from time to time, or reproductions thereof in color, black and white or otherwise made through any media. I hereby waive any right that I may have to inspect or approve the finished products or the advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge and agree to save harmless POP, its legal representatives or assigns and all persons acting under its permission or authority, from any liability in connection with the use of the photographs as aforesaid or by virtue of any alteration, processing or use thereof in composite form, whether intentional or otherwise, as well as any publication thereof. I understand that the photographs taken by POP will be included into stock files. I agree that the photographs, the transparencies thereof and the rights to copyright the same, shall be the sole property of POP, with full right of lawful disposition in any matter. I hereby grant permission to POP to photograph my student participating during activities to use the photographs in POP audio-visual and printed materials without compensation or approval rights. I hereby grant permission to POP the right to use, reproduce, and/or distribute photographs, films, videotapes, and sound recordings of my student, without compensation or approval rights, for use in materials created for purposes of promoting the activities of POP, St. Francis de Sales, Impact Charter School West, and any other POP locations.

I acknowledge and understand there are inherent risks in the activities that are included in POP’s program. I will assume the risk associated therewith, whether known or unknown to me at this time. I recognize that my child’s participation in POP is a privilege and as a consideration for this privilege, I release POP, St. Francis de Sales, Impact Charter School West, and any other POP locations including their employees, agents, members, directors and trustees from responsibility for my child’s accidental physical injury, including death or illness, and loss of personal property while or during POP sponsored activities. This release is also intended to include all claims made by my family, estate, heirs, personal representative or assigns.

I, the undersigned, consent to POP obtaining emergency medical care for my child in the case of an emergency.

I, the undersigned, consent to POP administering minor first aid on my child in the event of a minor injury.

The registration fee for each student attending POP Summer Program is $30 and is non-refundable. Once my child's enrollment is confirmed, I will be sent further instructions for how to make any necessary tuition payments. If I do not pay the $30 upon submission of this form, my child's enrollment will be incomplete and their spot will not be reserved.

By checking this box, you agree that your electronic signature is the legal equivalent of your physical signature on this application.

By typing your name below, you are signing this application electronically.