Name of the person who will be participating in workshops and other activities.

Choose the workshops you would like to attend!  Please see our website for descriptions. https://c-4a.org/happenings/48-hour-old-time-jam/.

Workshops are $5 each, or take all four sessions for $15!  Please see below for discussion about available scholarships and payment options.

For anyone who wants to play a dance piece and receive comments from our judges!  Recommended styles include hoedown, breakdown, waltz, fiddle rag, Irish jig or reel, or other traditional dance pieces.  This event is not suitable for classical forms like rondos, sonatas, etc.  Please see our website for more details.  https://c-4a.org/happenings/48-hour-old-time-jam/ 

There is a $5 registration fee to perform in the anti-contest. Please see below for discussion about available scholarships and payment options.

We hope we don't need to use this, but who should we call if you have a medical emergency?

Does student have any medical conditions, concerns, or modifications we should be aware of?  This information will be shared only with relevant C4A staff.

We are asking $5 for each workshop, or $15 for all 4 sessions.  

The fee to register to perform in the Fiddle Anti-Contest is $5.

Thanks to funding from an Urbana Arts & Culture grant, we are able to waive payment in the case of financial need. Please contact us if you require financial assistance.  

Please select your payment option below. Use this link to make your payment online via credit card.  
https://omella.com/0rp1m 

Payment may also be made by check mailed to C4A at 103 N Race St, Urbana IL 61801.
We can also accept cash payment; please email or call us to make an appointment to drop it off.  
mailto:info@c-4a.org  217-384-5150

Please read and understand the Consent and Acknowledgement and Medical Release and Authorization below and then sign in the Confirmation Area below before submitting this form.

I (student) hereby give my approval for my participation in any and all activities prepared by the Community Center for the Arts (C4A) during the selected activities(s). I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Community Center for the Arts, and all its respective officers, agents, and representatives from any and all liability for injuries to said student arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to myself or my guests, I hereby waive all claims against the Community Center for the Arts including all instructors, staff, and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Photographs and videos taken during our activities may be used for our promotional purposes without your further consent.  We will not publish or release images that are inappropriate or identify students by name or otherwise reveal their identities.  

Students' names may be listed in programs, online pla, or other media.  They will not be listed in a way that identifies individuals.  Said media will be available to the student and his/her family.

I agree to follow safety protocols,  as listed on the C4A website and in-house signage, in response to COVID-19 or other health concerns.

Students, their families, and their guests are all responsible for their own safety during participation in our events, whether on or off our premises.  

Students, their families, and their guests are all responsible for their own belongings and equipment during participation in our events, whether on or off our premises.

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child* in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Community Center for the Arts and its affiliates including Directors, teachers, staff, and volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

*If an adult student, the same release and authorizations apply, with contact attempt being made with designee listed under emergency contacts.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.