Basstravaganza 2019 Registration
Cost: $375 per session
Session Wishing To Register For: *
Student Name
Your answer
Student Age
Your answer
School Name *
Your answer
Grade Completed
Your answer
Private Teacher
Your answer
Years Experience
Your answer
Did you learn a piece for Solo and Ensemble?
If "Yes," what piece did you play?
Your answer
T-Shirt Size
Mother/Father/Guardian Name
Your answer
Home Phone #
Your answer
Day Time Phone #
Your answer
Parent/Guardian Email
Your answer
Address
Your answer
Medical Release
Name of Minor
Your answer
Date of Birth
Your answer
Emergency Contact #1
Your answer
Emergency Contact #1 Phone
Your answer
Emergency Contact #2
Your answer
Emergency Contact #2 Phone
Your answer
Insurance Company
Your answer
Policy #
Your answer
Doctor Name
Your answer
Doctor Phone #
Your answer
List any pertinent medical history or information: (allergies, medication, etc.)
Your answer
While the leadership of the Basstravaganza will take every ordinary precaution for the safety of each participant, it is understood that the participation in the activities is at his/her own risk. In the event that I am unable to be reached, in the case of injury or illness, I
(mother/ father/guardian)
Your answer
hereby give permission for treatment as deemed necessary by the staff. I also release Basstravaganza and its leaders and the Church of the Good Shepherd of liability in case of injury incurred by my child,
Your answer
Media Release
I,
(Parent/Guardian)
Your answer
give permission for my child
Your answer
to appear in promotional material for Basstravanganza summer camp. A video/picture of their performance in the July 2019 concert may be used to promote the camp in 2019 and beyond. Prior screening of this material will be available upon request.
Date
Your answer
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