Summer Jazz Factory Registration 2019
STUDENT REGISTRATION
Please read the full description on our website www.summerjazzfactory.org to determine your eligibility for the program. Students must register on this form, receive a follow-up communication from our staff, and pay the tuition fee in order to be fully enrolled.
Student Last Name *
Your answer
Student First Name *
Your answer
Student Age *
Your answer
Student Birth Date *
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DD
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YYYY
Student Allergies *
Your answer
Student Medications *
Your answer
Student Grade (2019-20 school year) *
Your answer
Student Email Address (one that they use in the summer) *
Your answer
Parent Email Address *
Your answer
Parent/Guardian Name (first, last) *
Your answer
Parent Cell Phone Number *
Your answer
Student Cell Phone Number *
Your answer
Home Address (include city, state, and zip) *
Your answer
Student Primary Instrument *
Your answer
Student Secondary Instrument (if applicable)
Your answer
Name of Your Current School *
Your answer
Current Band/Orchestra Director's Name *
Your answer
Private Music Instructor's Name (if applicable)
Your answer
How did you hear about us? (if another student/family told you, please select "Other" and give us their name) *
If another Jazz Factory student or family referred you, please give us their name so they get credit for our "finder's fee" program.
Your answer
Adult Tee Shirt Size *
Release of Liability for Program Participation
I agree to indemnify and hold harmless The Center for Performing and Fine Arts (hereinafter referred to as CPFA), its Employees, Agents, Officers, Board Members, Volunteers or any other person against loss or expense, including attorney fees, due to any bodily injury, personal injury or property damage at any other activity sponsored by or conducted by Theatre, or while visiting any facilities owned by, leased by, or controlled by CPFA. CPFA guarantees that all equipment and facilities are in good repair and are appropriate for the purposes to which they will be put, and personnel are appropriately trained and screened.It is understood and agreed that this Release of All Liabilities shall remain in force for not more than one year from the date of this Release. The release is recorded through a computer system, along with the date of agreement. I am either the student named above, or I am a parent/guardian acting on behalf of a child under 18 years of age.
Please electronically sign the Release of Liability by choosing from the following options: *
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