2012 registration by iQckp8W1


									                                             University of Evansville Summer Music Camp 2012 Registration

Please print and complete the registration form, submit along with payment by May 31st, 2012 (forms sent after this date will incur a $15 late registration fee). Payment is
refundable (less an admin fee of $25.00) if enrollment is cancelled by June 11th, 2012. For more information, contact Dr. Tim Groulx at (812) 488-2743 or tg90@evansville.edu

Name of Student                                                                                  Street Address                                   City/State/ZIP:

Best Number for telephone Contact (             )                                                Best e-mail for official correspondence:

Alternative Number for telephone Contact (            )                                          Alternative e-mail for official correspondence:

Instrument                                                                                       Shirt Size (adult sizes) (circle one)            S        M         L         XL    XXL

School you attended 2011-2012 school year: _____________________________                         Grade you were in during 2011-2012 school year:________________

Name(s) of Parent(s)/Guardian(s)                                                                                              ____________________________________

Please describe any allergies, relevant medical history and current health concerns.

In case of emergency, my child should be taken to:

Name of physician:                                                                               Insurance Carrier:

“By submitting this form, I authorize my child to participate in all activities of The University of Evansville Band Camp, June 24-29, 2012. I understand he/she is expected to observe
all camp rules and in case of failure to do so, I am responsible for immediate transportation home. I further understand and agree that there will be no refund of camp fees in the
event of my child’s dismissal from any portion of the camp. Furthermore, I hereby give permission for emergency medical treatment of the child named above by his/her physician
or a physician on call.”

Parent Signature:                                                                                Date:

Please register our child for:
______ DAY CAMP:                  $175* (Sunday from 4-5:30pm, Monday-Friday 8:30-3:30, plus Friday night concerts. Hot lunch Mon-Fri included)
______ OVERNIGHT CAMP: $435* (check in at 3:00 Sunday, checkout Friday 4-5pm, 3 meals/day beginning with dinner Sun., ending with dinner on Fri.)
*High school students who have paid full price to participate the 2012 UE Wesley Shepard Honor Band may subtract $100 from the above prices. Any registrations sent
after May 31st must include $15 late registration fee.

PAYMENT METHOD for UE MUSIC CAMP 2012 (Check One): MAIL to: UE Music Camp, c/o Tim Groulx, 1800 Lincoln Avenue, Evansville IN 47722
[ ] Payment by Check via Mail - (Payable to: University of Evansville)
[ ] Credit Card Payment via Mail OR scan & email (to tg90@evansville.edu) - The University of Evansville accepts Visa, MasterCard, and Discover (sorry, no American Express)

Credit Card No.: ________________________________________                     Expiration Date _________               3-digit code on back:_________

Print Name of Card Holder _________________________________________                              Signature of Card Holder ________________________________________________

Address of Cardholder if different from above ______________________________________ Phone # of Cardholder if different from above: (                               ) ___________________

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