2012 registration by iQckp8W1

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									                                             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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