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 ________________

School ______________________________________________________________________________________________________

Instrumental/Vocal Teacher____________________________________________________________________________

Please Indicate the Camp(s) You Are Attending
[ ] Sing, Say, Dance, Play June 14-17 ($40)
[ ] Stories and Songs June 20-23 ($40)
[ ] Barred Instrument Band June 28-July 1 ($45)
[ ] Imagination Camp For Beginning Strings June 7-11 ($100)
[ ] Advanced String Ensemble June 14-17 ($125)
[ ] Vocal Arts Performance Camp July 5-9 ($150)
[ ] Camp Allegro Piano Workshop July 31 ($23- Beginners & $35 - Intermediate and Advanced)
[ ] Private Lessons May-August (Call 274-5357)

PAYMENT and REFUND INFORMATION

Payment in full is due by the first day of each camp. Full refunds (minus a $15.00 clerical fee) are available if a written request is received by the Academy staff at least 7 days prior to the first day of the camp for which the student is enrolled. After the 7 day deadline, 50% of the enrollment fee (minus a $15.00 clerical fee) will be refunded upon receipt of a written request. No refunds are available after the camp has begun.

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.

SCHOLARSHIPS AVAILABLE
Scholarships are available for camps and private lessons if you apply for them before May 10th. You can apply for a scholarship by going to www.kucinskiacademy.com and clicking on the word “forms” to apply.

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