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Name______________________________________________________________________________________
Last First Middle
Initial Name You Wish to Be Called
Address___________________________________________________________________________________
Street
City
State
Zip
E-Mail
Address_____________________________________________________________________________
Date of
Birth______________________________________________ Age______ Male _____
Female _____
Parents/Guardians'
Name_____________________________________________________________________
Phone (______)
___________________________ Alternate Phone (______)
____________________________
Other Emergency
Contact
Person_______________________________________________________________
Relationship to
Student______________________________________ Phone Number (____)
_______________
List
Allergies_______________________________________________________________________________
Doctor and
Phone___________________________________________________________________________
Do you plan to
(please check ) ____Live on Campus ___Commute Daily
___Attend Night Classes
____Both Weeks ___First Week Only ___Second Week
Only
If You Live on
Campus, Roommate Preference________________________________________
PRIVATE LESSONS -
Five 30-minute lessons, Additional $60 (Please check lessons desired)
_____Piano _____Voice
_____Quartet/Trio Training _____Songwriting _____Fiddle _____Guitar
_____Mandolin _____Banjo _____Dulcimer _____Electric Bass Guitar
Teacher
Preference_______________________________
Student
Signature____________________________________________________
Date__________________
Emergency Release
In the event of
illness or accident which requires medical treatment, at a time when a
parent or legal guardian cannot be located or contacted in a timely
fashion, I give permission for CVSGM and representatives thereof to
secure medical emergency treatment and do hereby give permission to the
physician, selected by the adult leader in charge, to hospitalize,
secure proper anesthesia, or to order injection or surgery for my child,
___________________________. I will not hold CVSGM, its representatives,
or the medical personnel liable. This is done with the understanding
that every attempt will have been made to contact a parent or other
authorized person/guardian.
Parent/Guardian's
Signature______________________________________________
Date_____________
IMPORTANT:
PARENT/GUARDIAN MUST SIGN APPLICATION OF MINOR BELOW 18 YEARS OF AGE.
THE NON-REFUNDABLE
REGISTRATION FEE AND A COPY OF HEALTH INSURANCE COVERAGE FOR STUDENT
MUST BE ENCLOSED WITH THE APPLICATION.
Students are
accepted without regard to race, creed, or national origin. Enrollment
limited due to space available.
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