Waiver and Policy
S
tatement
has my permission to participate in lessons and
/
or classes
through the Southern Miss Piano Institute at the USM School of Music on the campus of the
University of Southern Mississippi. I understand there are risks, and that I
/
my child
participate(s) in this program at my
/
his own risk and that the University of Southern
Mississippi will not be responsible for any personal injuries, property damage, or related
expenses, including but not limited to medical expenses, incurred as a result of my/my child’s
participation in this program. I further agree to indemnify and hold harmless the University of
Southern Mississippi and its agents and representatives from any and all liability for any
harm, injury, damage, claims, causes of action, and all costs, including attorneys fees, that may
result from, arise out of, occur during, or are in any way connected with my/my child’s
participation in lessons, classes or other activities of the Southern Miss Piano Institute/USM
School of Music.
I understand and accept the policies of the Southern Miss Piano Institute as stated in
the accompanying pages and accept responsibility for charges and fees incurred.
I will allow the Southern Miss Piano Institute to use photographs, video, and recordings
made at USM or at Institute functions, involving the student hereby enrolled.
Student’s signature or parent
/
guardian signature if student is under 18:
Name (printed)
Signature Date
Please return this completed registration form to:
Sue Price, SMPI Administrator
209 Lynnwood Circle
Hattiesburg, MS 39402
Should you have questions, please contact:
Sue Price, SMPI Administrator
(601) 268-9620 (home)
(601) 329-3537 (cell)
Email: sueboydprice@gmail.com
