KIDS ACADEMY APPLICATION FORM 1 STUDENT INFO2 MUSIC PREFERENCES3 OTHER INFO4 WAIVERS5 PAYMENT Select Academy Start Date*April 2019July 2019First Name*Last Name*Parent / Guardian Email* Parent / Guardian Phone*Is your current mailing address US or International?*selectUSInternationalUS Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code International Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country OLD Address Line 1*OLD Address Line 2OLD City*OLD State / Province*Outside of the USA or CanadaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaDistrict of ColumbiaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin IslandsArmed Forces AfricaArmed Forces AmericasArmed Forces CanadaArmed Forces EuropeArmed Forces Middle EastArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonOLD Zip / Postal Code*Country of Citizenship*UNITED STATESCANADAAFGHANISTANALBANIAALGERIAAMERICAN SAMOAANDORRAANGOLAANGUILLAANTARCTICAANTIGUA AND BAR.ARGENTINAARMENIAARUBAAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIABOSNIABOTSWANABOUVET ISLANDBRAZILBRITISH INDIANBRUNEI DARUSS.BULGARIABURKINA FASOBURUNDICAMBODIACAMEROONCAPE VERDECAYMAN ISLANDSCENTRAL AFRICANCHADCHILECHINACHRISTMAS ISLANDCOCOS ISLANDSCOLOMBIACOMOROSCONGOCONGO, THE DEM.COOK ISLANDSCOSTA RICACROATIACUBACYPRUSCZECH REPUBLICCÔTE D'IVOIREDENMARKDJIBOUTIDOMINICADOMINICAN REP.ECUADOREGYPTEL SALVADOREQUATORIAL GUIERITREAESTONIAETHIOPIAFALKLAND ISLANDSFAROE ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAFRENCH POLYNESIAFRENCH SOUTHGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUAMGUATEMALAGUERNSEYGUINEAGUINEA-BISSAUGUYANAHAITIHEARD ISLANDHOLY SEE VATICHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRAN, ISLAMICIRAQIRELANDISLE OF MANISRAELITALYItalyJAMAICAJAPANJERSEYJORDANKAZAKHSTANKENYAKIRIBATIKOREA, DEM.KOREA, REP.KUWAITKYRGYZSTANKosovoLAO PEOPLE'S DEM.LATVIALEBANONLESOTHOLIBERIALIBYAN ARABLIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIAMADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISL.MARTINIQUEMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIAMOLDOVAMONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDNETHERLANDSNEW CALEDONIANEW ZEALANDNICARAGUANIGERNIGERIANIUENORFOLK ISLANDNORTHERN MAR.NORWAYOMANPAKISTANPALAUPALESTINIANPANAMAPAPUA NEW GUINEAPARAGUAYPERUPHILIPPINESPITCAIRNPOLANDPORTUGALPUERTO RICOQATARROMANIARUSSIAN FEDERATIONRWANDARÉUNIONSAINT BARTHÉLEMYSAINT HELENASAINT KITTSSAINT LUCIASAINT MARTINSAINT PIERRESAINT VINCENTSAMOASAN MARINOSAO TOME AND PRI.SAUDI ARABIASENEGALSERBIASEYCHELLESSIERRA LEONESINGAPORESLOVAKIASLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH GEORGIASPAINSRI LANKASUDANSURINAMESVALBARDSWAZILANDSWEDENSWITZERLANDSYRIAN ARAB REP.SwitzerlandTAIWAN, PROVINCETAJIKISTANTANZANIA, UNITEDTHAILANDTIMOR-LESTETOGOTOKELAUTONGATRINIDAD AND TOB.TUNISIATURKEYTURKMENISTANTURKS AND CAICOSTUVALUTahitiUGANDAUKRAINEUNITED ARAB EMIR.UNITED KINGDOMUNITED STATES MIN.URUGUAYUZBEKISTANVANUATUVENEZUELAVIET NAMVIRGIN ISL. U.S.VIRGIN ISLANDSWALLIS AND FUT.WESTERN SAHARAYEMENZAMBIAZIMBABWEÅLAND ISLANDSDate of Birth* Gender* Male Female Prefer Not To Say Fluent in English?*YesNo Instrument*GuitarBass GuitarDrumKeyboardVocalHow many years of playing instrument?*Please enter a number from 0 to 17.Ever played with other musicians?*YesNoEver taken a music class?*Yes, private lessonYes, group lessonNoMusic Equipment Owned?*Ever read music or tablature?*YesNoStyle Preference* Country Funk Hip Hop Metal Jazz Latin Pop Rhythm & Blues Rock Soul Favorite Artist?*Favoriute Song(s)?* What would you like to get out of this program?*Anything else you would like us to know? UNDER 18 Waiver Acknowledgement*I AgreeParent or Guardian of applicant agrees that as a condition to applicant’s participation in MI Youth Academy, their Parent or Guardian must also sign the separately provided (i) Medical Release and Participation Agreement, (ii) Waiver of Liability and Release, and (iii) arbitration agreement. The Parent or Guardian also agrees to cause his/her child to abide by Musicians Institute’s rules and policies, including its Student Conduct Code. Applicant agrees that they are under 18 years of age, have entered true and correct information above and will abide by Musicians Institute’s rules and policies, including its Student Conduct Code if accepted to the MI Youth Academy program.Photo Release*I AgreeI do hereby give Musicians Institute/Campus Hollywood, their assigns, licenses, and legal representatives the irrevocable right to use my picture, portrait or photograph in all forms of media and in all manners, including video, lm, composite or distorted representations, for advertising, trade, or any other lawful purposes, and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith.Waiver of Arbitration*I confirm that I have read and understood the foregoing, a knowledge and agree to its terms, and sign it freely and voluntarily.AGREEMENT FOR BINDING ARBITRATION AND WAIVER OF JURY TRIAL For signature by Student or Parent/Guardian (If Student is under 18) confirm that I am a parent or the legal guardian of the child identified below (“Student”) and I am fully competent to sign this Agreement for Binding Arbitration and Waiver of Jury Trial. In consideration of the Student being permitted to enroll in Musicians Institute and/or participate in any program or event offered by or conducted on the premises of Musicians Institute, I con rm and agree to the following: On behalf of myself as well as on behalf of the Student, I agree that any dispute arising from the Student’s enrollment in Musicians Institute, no matter how described, pleaded or styled, shall be resolved by binding arbitration under the Federal Arbitration Act conducted by the American Arbitration Association (“AAA”) under its Commercial Rules and Supplementary Procedures for Consumer-Related Disputes. The award rendered by the arbitrator may be entered in any court having jurisdiction. TERMS OF ARBITRATION 1. On behalf of myself as well as on behalf of the Student, I irrevocably agree that any dispute between Musicians Institute and the Student (and/or between Musicians Institute and me relating to the Student) shall be submitted to arbitration. 2. Neither I nor the Student shall file or maintain any lawsuit in any court against Musicians Institute relating to or otherwise arising from the Student’s enrollment in Musicians Institute and/or the Student’s participation in any program or event offered by, or conducted on the premises of, Musicians Institute. Nor shall Musicians Institute file or maintain any lawsuit in any court against the Student or me relating to or otherwise arising from the Student’s enrollment in Musicians Institute and/or the Student’s participation in any program or event offered by or conducted on the premises of Musicians Institute. Any suit filed in violation of this Agreement shall be dismissed the court in favor of an arbitration conducted pursuant to this Agreement. 3. The costs of the arbitration filing fee, arbitrator’s compensation and facilities fees will be paid by Musicians Institute, to the extent these fees are greater than the applicable court filing fee. Musicians Institute shall not be solely responsible for arbitration costs be on those for an individual student’s claim. 4. The arbitrator’s decision shall be set forth in writing and shall set forth the essential findings and conclusions upon which the decision is based. 5. Neither I nor the Student shall be allowed to combine or consolidate any claim I or the Student may have against Musicians Institute with those of other students, such as in an action on a class wide or representative basis, and the arbitrator shall have no authority to conduct a class action arbitration. I understand that I and the Student may opt out of this non-consolidation (no class action arbitration) provision by delivering a written statement to that effect to Musicians Institute within 30 days after the date that I sign this Agreement. 6. Any remedy available from a court under law shall be available in the arbitration. 7. I acknowledge that I and/or the Student may, but need not, be represented by an attorney at the arbitration. 8. I acknowledge that nothing in this Agreement prohibits me or the Student from filing a complaint with the California Bureau or Private Postsecondary Education or any other regulatory agency. Additionally, I understand that MI, the Student and I each retain the right to seek relief in small claims court, if the claim qualifies for handling by such a court. ACKNOWLEDGMENT OF WAIVER OF JURY TRIAL By my signature below, I acknowledge that Musicians Institute, the Student and I are each irrevocably waiving rights to a trial by jury, and are selecting instead to submit any and all claims to the decision of an arbitrator instead of a court. I understand that the award of the arbitrator will be binding, and not merely advisory. AVAILABILITY OF AAA RULES AND PROCEDURES FOR FILING AN ARBITRATION I acknowledge being informed that I may obtain a copy of the AAA Commercial Rules and Supplementary Procedures for Consumer-Related Dis- putes, at no cost, from the Director of Admissions or the Registrar of Musicians Institute at any time or at www.adr.org. If the Student or I desire to file for arbitration, I understand that I may contact the Director of Admissions or the Registrar of Musicians Institute who will provide me with the telephone number and address of the American Arbitration Association in Los Angeles, California. I understand that I should then contact the AAA which will provide me with the appropriate forms and detailed instructions. I also understand that I may nd the con act information for the AAA in Los Angeles and necessary forms at www.adr.org. I understand that I should bring a copy of this Agreement to the AAA.Waiver of Liability and Release*I confirm that I have read and understood the foregoing, a knowledge and agree to its terms, and sign it freely and voluntarily.For signature by Student or Parent/Guardian (If Student is under 18) In consideration of the child identi ed below (“Student”) being permitted to enroll in Musicians Institute and/or participate in a program or event offered by, or conducted on the premises of, Musicians Institute, I con rm and agree to the following: 1. I con rm that I am a parent or the legal guardian of the Student and I am fully competent to sign this waiver of Liability and Release. 2. On behalf of myself as well as on behalf of the Student, we HEREBY RELEASE, WAIVE AND DISCHARGE Musicians Institute, its employees, teachers, assistants, staff, agents, independent contractors, managers, of cers, directors, owners, shareholders, subsidiaries and other af liates ( Releasees”) from, and agree and covenant not to sue Releasees for, any claim, liability, or demand of any kind or on account of any personal injury, temporary or permanent disability, death, property damage, or other damages, whether caused by the negligence of Releasees or otherwise, resulting from or in any way associated with the Student’s enrollment in Musicians Institute, the Student’s participation in any Musicians Institute program or event, the Student’s presence on the premises of Musicians Institute, or the Student’s use of any of Musicians Institute’s facilities, amenities or services. Further, on behalf of myself as well as on behalf of the Student, I agree and covenant to indemnify each of the Releasees for, and hold each of the Releasees harmless, from any such claims, liabilities or demands. 3. On behalf of myself as well as on behalf of the Student, we further HEREBY VOLUNTARILY ASSUME ALL RISKS of personal injury, including temporary or permanent disability or death, property damage, economic losses, and/or other damages resulting from or in any way associated with the Student’s enrollment in Musicians Institute, the Student’s participation in any Musicians Institute program or event, the Student’s presence on the premises of Musicians Institute or the Student’s use of any of Musicians Institute’s facilities, amenities or services. 4. On behalf of myself as well as on behalf of the Student, we acknowledge and agree that this Waiver of Liability and Release is intended to be, and is, a complete release and discharge of all rights I or the Student has, or may have, against any of the Releasees for personal injuries and/or temporary or permanent disability or death and/or property loss/damage that the Student sustains while enrolled in Musicians Institute, participating in any Musicians Institute program or event, while on the premises of Musicians Institute, or arising from the Student’s use of any of Musicians Institute’s facilities, amenities, services. On behalf of myself as well as on behalf of the Student, we further acknowledge and agree that no action will be taken by or on the Student’s behalf respect to any such rights, it being understood that this release shall be binding upon me and the Student, and each of our assigns, heirs, executors and administrators or other personal representatives. 5. On behalf of myself as well as on behalf of the Student, we hereby waive the bene t of the provisions of Section 1542 of the C vil Code of the State of California, which provides as follows: “A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have materially affected his or her settlement with the debtor.” 6. On behalf of myself as well as on behalf of the Student, we agree that the Student shall abide by Musicians Institute’s rules and policies including, without limitation, Musicians Institute’s Student Conduct Code (which I understand can be found in Musicians Institute’s Course Catalog, or on its website at [http://www.mi.edu/Upload/pdf/MI-Course-Catalog.pdf], on page 26. 7. On behalf of myself as well as on behalf of the Student, we understand and agree that this Waiver of Liability and Release shall be governed by the laws of the State of California without regard to its choice of law principles. 8. On behalf of myself as well as on behalf of the Student, we agree that any dispute relating to this Waiver of Liability and Release, the Student’s enrollment in Musicians Institute, the Student’s participation in any Musicians Institute program or event, the Student’s presence on the premises of Musicians Institute, or the Student’s use of any of Musicians Institute’s facilities, amenities or services, no matter how described, pleaded or styled, shall be resolved through binding arbitration under the Federal Arbitration Act conducted by the American Arbitration Association (“AAA”) in Los Angeles, California under its Commercial Rules. On behalf of myself as well as on behalf of the Student, we acknowledge that, as a condition to enrollment or participation in any Musicians Institute program or event, the Student will be required to sign a separately provided “Agreement for Binding Arbitration and Waiver of Jury Trial.”Signature of Parent of Guardian* Youth Academy Tuition*Tuition Deposit OnlyTuition Full AmountNOTE: Balance due before classes beginTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.