Registration For Rockin’ Horse Academy July 19th through July 31st, 2010

PLEASE PRINT, FILL OUT, SCAN AND EMAIL TO: muddythedose@yahoo.com

Or mail to:
ROCKIN’ HORSE ACADEMY
10643 Tuxford St.
Sun Valley, California 91352

Student First and Last Name:_____________________________________________________________________

Stage Name (Optional, but encouraged): ___________________________________________________________

Age: [ ] Years Young

Gender: Rocker [ ] Rockette [ ]

Instrument/s: Primary _________________ Secondary __________________

Do you also sing? [ ] Yes [ ] No How Long? [ ] Years

Experience:
Writing: [ ] Year/s Performing: [ ] Year/s

Name three of your favorite Bands or Artists: _________________________________________________________

______________________________________________________________________________________________

Emergency Contact Info: _________________________________________________________________________

Name of Parent/s or Guardian: ____________________________________________________________________

Home Telephone Name and # _____________________________________________________________________

Work Telephone Name and # _____________________________________________________________________

Cell Telephone Name and #_______________________________________________________________________

Email Address: _________________________________________________________________________________

Friend referral or early sign up (By May 1st) discount: $50.00

(That’s right, 50 bones, bucks, skins, greenbacks....you get the message!)

Referral Name and Contact :_______________________________________________________________________

Payment options: Cash or Check; Non Refundable deposit of $500.00 upon Sign Up and balance payable In Full
on or before July 19th 2010. Cancelations received after July 10th will incur a $175 cancelation fee. Consistent
disruptive or dangerous behavior will result in dismissal from the academy. Every effort will be made to contact and
inform parent or guardian of the situation in order to maintain enrollment. Parents are expected to behave in a
supportive manner - Please, no Stage Parenting!

Students will be responsible for provision and care of their own instruments, and be required to bring and wear ear
plugs at various times during performances and rehearsals.

Academy must have a minimum of 10 students and maximum of 25 to book. Refunds will be given by July 30th in
the event of cancelation. There will be a second session in August in the event of a surplus of enrollees or the
overwhelming desire by parents to have another two weeks of kid free adult time, perhaps to re-kindle the old
flame or work on that tan.

ROCKIN’ HORSE ACADEMY reserves the right to use recordings, video and pictures of all activities including all
kids participating in the academy for promotional purposes.

Yes, Rockin’ Horse Academy has my permission to use my child's image

Please sign here: _______________________________ Date: ____________________

Writing credit for all songs composed at Rockin’ Horse Academy will be shared by all participants and teacher,
regardless of individual input. Participants retain unlimited Non-Commercial use of compositions and recordings. All
master recordings are to remain the sole property of Mark Dutton and any commercial use of such recordings is
forbidden without express permission.
Parent or Guardian agrees to forever release, indemnify and hold harmless Summerwood Stables, Rockin’ Horse
Academy, Mark Dutton, Nina Heller and their employees from any and all liability and/or damage sustained while
participating in the activities of the Academy.
Signature below acknowledges that you have read, understand and agree to the policies stated and are legally
entitled to sign on the behalf of the participant.

Parent/Guardian Signature: ________________________________________Date: _____________________

Student/Participant Signature: ______________________________________ Date: _____________________

RHA-REGDOCV1-04022010