Leo Kucinski Academy of Music SummerDayCamps

Student’s Name ______________________________________________________________________________________________

Home Address _______________________________________________________________________________________________

City/State/Zip _______________________________________________________________________________________________

Parent(s)Name(s) _____________________________________________________________________________________________

Home Phone _____________________________________________Cell Phone __________________________________________

E-Mail Address ______________________________________________________________________________________________

Student’s Age __________________________ Date of Birth ______________________ Male/Female(circle) Grade _____________

Instrument to be played at Camp _________________________________________________________________________________

Instrument Make ___________________________________ Model ________________________ Serial # _____________________

School ______________________________________________________________________________________________________

Band Director/Private Teacher ___________________________________________________________________________________

Please Indicate the Camp(s) You Are Attending
[ ] Woodwind Camp June 1-3 ($80)
[ ] Brass Camp June 1-3 ($80)
[ ] Percussion Camp June 1-3 ($80)
[ ] Foundations of Singing June 8-26 (private lessons) ($100)
[ ] Foundations of Singing June 8-26 (private & group lessons) ($80)
[ ] Jazz Camp June 15-18 ($140)
[ ] Sing, Say, Dance, Play June 15 - 25 ($45)
[ ] World of Music Drumming June 15 - 25 ($45)
[ ] Barred Instrument Band June 15 - 25 ($55)
[ ] Beginning String Camp July 13-17 ($80)
[ ] Summer Composition Camp July 20-24 ($125)
[ ] Vocal Auditions 101 Camp August 11-14 ($100)

REFUND INFORMATION

It is possible to withdraw your application and receive a refund if the request is made at least 7 days prior to the first day of the camp for which you are enrolled. After the 7 day deadline, only 50% of the enrollment fee will be refunded. Once the camp has started, no money will be refunded for any portion of the camp. When requesting a refund, please do so in writing. A $15 clerical fee is deducted from ALL refunds and is done during processing. Therefore, it is not necessary for you to include the fee with the refund request.

PHOTO RELEASE

LKAM is hereby granted permission to take photographs of the students to use in brochures, websites, posters advertisements and other promotional materials the school creates. Permission is also hereby granted for the school to copyright such photographs in its name.

LUNCH

If the student is attending a class that goes through the lunch hour, they will need to bring a sack lunch.

PERMISSION FOR MEDICAL TREATMENT

I/We, ____________________________________________ as parent(s) of ______________________________________________

give permission to any physician, medical doctor, nurse, or other medical personnel for treatment of injury or illness at the request of any member of the LKAM summer music camp staff or other Morningside College employee during participation in the Summer Camp.

Signature___________________________________________________________________________Date_____________________

Medical Insurance Company_______________________________________ Policy #______________________________________

Name and Phone # of family physician ___________________________________________________________________________

List any particular medical problems, allergies, regular medications, dosages, etc.:__________________________________________

____________________________________________________________________________________________________________

REGULATIONS FOR STUDENTS: From the first camp meeting until the end of camp each day, you will be under the supervision and guidance of the Music Camp staff. All students are required to attend all scheduled activities and rehearsals. Disruptive behavior will not be tolerated and could result in dismissal from camp. Morningside College accepts no responsibility for student behavior, and in keeping with College policy, students are not to possess or consume alcohol, tobacco, or any controlled substances while on campus. No types of weapons, toy or otherwise, are allowed, and anything of this type will be confiscated and turned over to campus security.

Student Signature __________________________________________________________________Date ______________________

Parent/Guardian Signature ___________________________________________________________ Date ______________________

Please direct any questions to:

Melissa Cummins/Suzy Turnquist LKAM Summer Camps

Morningside College 1501 Morningside College Sioux City, IA 51106 turnquist@morningside.edu

www.kucinskiacademy.com