Campers Name:
     
First                                 Middle             Last

Boy   Girl       Birth Date:    Grade Fall '04
                                                eg. 01/02/88

Address: 

City:   State:  Choose a State Alabama Alaska Arizona Arkansas Bahamas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming      Zip: 

Phone:       Bus.: 

Med. Ins. Co.:    Policy#: 

Family Dr.:       Phone: 

Last Tetanus:       Hospital: 

Any physical condition requiring attention (allergies)

I authorize emergency medical treatment and/or hospitalization if necessary for this camper.

Parent or Guardian Signature: 
By typing in your name above, you are authorizing your signature.

MUSIC WEEKS  (Sunday to Sunday) - I wish to enroll for the following: 
             1 week or  2 weeks

 

WEEK 1.............MAY 25 - JUNE 1    WEEK 2.............JUNE 1 - 8    WEEK 3.............JUNE 8 - 15    WEEK 4.............JUNE 15 - 22

WEEK 5.............JUNE 22 - JUNE 29    WEEK 6.............JUNE 29 - 6    WEEK 7.............JULY 6 - 13    WEEK 8.............JULY 13 - 20

   ART WEEK.......................................SUNDAY, JULY 20 - SATURDAY, JULY 26
   CHESS WEEK...................................SUNDAY, JULY 20 - SATURDAY, JULY 26

1st Choice:  Week #    Arrival / Departure Dates

2nd Choice:  Week #    Arrival / Departure Dates

Instrument I will play:      
Beginner   Intermediate  Advanced

I will rent this instrument from camp for $20 per week.
I am interested in Transfer class  
(Piano    Guitar   Band   Orchestra)

DEPARTURE TRANSPORTATION:  Parent  Guardian  Other 
If person not designated above takes children home or away from Camp, they must
sign out at the Office. 

Person assuming responsibility: 

Send my friend a brochure:   

Address: 

DEPOSIT FEE:  ONE WEEK $100, TWO WEEKS $200
WILL SECURE REGISTRATION

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