SUMMER MUSIC QUEST CAMP REGISTRATION/MEDICAL

REGISTRATION

Fill out the registration below... OR

Click here to download and mail in the form - DOC

Click here to download and mail in the Medical form - DOC

Full Name:
Nickname (if any):
Gender:
Age:
Birth Date:

Parents or Guardians (list names, addresses, and home and work phone numbers for all parents/guardians).

Mom		Dad
Name:		Name:
Address:		Address:
City:		City:
State:		State:
Zip:		Zip:
Phone
Mom home:		Dad home:
Mom work:		Dad work:
Mom cell:		Dad cell:

Most used e-mail address:

School:
Grade in 2012-2013:

Tee Shirt Size:

One part of camp includes class instruction on an instrument. Please choose the class you would like to be in:
Class Requirements:
Beginning Piano - This class is for beginners who have never taken piano lessons before.
Advanced Piano - Piano experience needed. We will learn to harmonize melodies from popular music.
Beginning Guitar - This class is for beginners. We will learn three basic chords and be able to play one or two songs by the end of the week. Class guitars are available for class. However, if you have one, please bring it.
Percussion - This class is for all levels. Drumming and other percussion instruments will be utilized.

Select class:

My child’s photos/voice be used for marketing purposes in posters, television, newspaper, internet, audio recording or other media sources.

Camper’s Signature:
Date:

By placing my name here I acknowledge that this is my signature and agree to the above statement.

Signature of Parent or Guardian:
Date:

By placing my name here I acknowledge that this is my signature and agree to the above statement.

MEDICAL

Participant’s Name:
Participant’s Address:
Home Phone:
Birthdate:
Parent/Guardian’s Name:

Home Phone:	Work Phone:
Cell Phone:	Cell Phone:

Emergency Numbers

Chorister’s Physician’s Name:	Phone:
Other Contact and Relationship to Chorister:	Phone:
Other Contact and Relationship to Chorister:	Phone:

Health History (Check all that apply.):

Diseases:	Allergies:	Chronic/Recurring Illnesses:
Chicken Pox	Hay Fever	Ear Infections
Measles	Asthma	Heart Disease
German measles	Insect Stings	Convulsions
Mumps	Ivy, Oak, etc.	Diabetes
Other:	Food or Drugs:	Other:

Details and explanations:

Describe any special medical or dietary regimen:

List any recent hospitalizations or medical treatment:

Does your child take regular medication?
If so, please give details:

AUTHORIZATION TO CONSENT TO HEALTH CARE FOR MINOR CHILD

I give my permission for a doctor, nurse or paramedic to administer any needed medical treatment to my son/daughter while traveling, performing, or rehearsing with Voices in the Laurel.

I further authorize any adult representative, driver, chaperone, or administrator from Voices in the Laurel to administer first aid treatment for my child.

This consent shall be effective from the date it is executed until the date I terminate it in writing or until this child is no longer in involved with Voices in the Laurel. By signing here, I indicate that I have the understanding and capacity to communicate health care decisions, am fully informed as to the contents of this document, and understand the full scope and importance if this document.

Signature of Parent or Guardian: Date:

By placing my name here I acknowledge that this is my signature and agree to the above statement.

This will allow you to confirm your information before purchasing your registration.

You may also download the form, fill it out and mail it in. Please complete and return with $85.00 payment (checks payable to Voices in the Laurel) at: Voices in the Laurel * P.O. Box 1581 * Lake Junaluska, NC 28745

Questions? Call (828) 734-8413