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Northwest Missouri State University

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Junior High School Music Camp Registration

Junior High School Camp: June 16-21
Entering grades 7-9 in 2008-09
Entry Deadline: June 6

*All fields are required except for roommate choice and additional purchased items.

Participant Information:

Type of Camp: Resident Camp ($310; $325 after June 6)
Commuter with meals ($210; $225 after June 6)
If attending as a resident camper, name of student with whom you wish to room:
First Name:
Last Name:
Gender: Male  Female
Age:
Grade in School:  (for 08-09)
Birthdate:  (format: MM/DD/YYYY)
Polo Shirt Size: (included in camp fee)
E-mail Address:
Note: We will communicate camp updates through e-mail.
Home Phone:

Parent Information:

First Name:
Last Name:
Address:
City:
State:
ZIP Code:
Work Phone:

Camper Information:

Name of School:
How many years have you attended Northwest's Music Camp (including this year)?
Were you a member of the 2007-08 High School Music Educator Association
All-District organization? (scholarship valued at $30)
Yes No
What state did you participate in?
What ensemble did you participate in?

If you participated in more than one district ensemble, please choose one for the purpose of this application.		 Choir
Band
Jazz Band
Orchestra
I did not participate
Name of instrument you play: Concert Band:
Orchestra:
Jazz Band:
None
Voice Part:

Soprano
Alto
Tenor
Bass
None

The set of activities in which you wish to participate: Band/Choir
Choir/Choral Tone
Band/Rhythm Reading
None

Optional Purchases:

Note: All optional purchases must be paid for today.

Would you like Private Lessons? Cost: $10 per 30-minute lesson

Yes No
How many lessons?

 

Would you like a Commemorative Camp T-Shirt? Cost: $15 per shirt

Yes No
How many t-shirts?

 

Would you like to pre-order a Compact Disc Recordings of the concert? Cost: $10 for single disc; $18 for two-disc set

Yes No
What type(s) of recordings would you like to preorder?
Friday Chamber Concert Quantity: Cost: $10
Saturday Finale Concert Quantity: Cost: $10
Two CD Set Quantity: Cost: $18
None  

Authorization for Medical Treatment:

I give permission for my child, named above, to be treated by the Northwest Missouri State University physicans and further authorize treatment at St. Francis Hospital in the event my child needs treatment the university physicians are unable to provide while in attendance at Northwest's Music Camp of Excellence.

Does your child have allergies to medication or food?
No
If yes, state:

Does the student require any special treatments or medication?
No
If yes, state:

Does your child have a chronic illness or disability?
No
If yes, state:

Do you give permission for the staff at the camp to administer over-the-counter medication (headache tablets, upset stomach forumlas, etc.) in the even your child required medications?
No
Yes

Is the child covered by health insurance?
No
If yes, please provide the following information:
            Company Name:
              Policy Number:

If your child requires specialized care or treatment, written permission from a family physician must accompany your child so that we may ensure care. Nortwhest Missouri State University Music Camp of Excellence is not responsible for payment of treatment.

Fee Information:

  • Minimum deposit of $150 required for residential campers.
  • Minimum deposit of $105 required for commuter campers.
Payment Option: I would like to pay the camp fee in full.
I would like to pay the camp fee in two
     installments.

Camp Fee: $
Scholarship Awarded: $
Optional Purchased Fees: $  
Amount Due Today: $ (camp fee + optional purchases)
Remaining Balance: $

Billing Information:

I would like to use the Parent Information above for the Billing Information.
Yes No
*First Name:
*Last Name:
*Street Address:
*City:
*State:
*ZIP Code:
*Phone:
*E-mail:

To retain a copy of this application for your records,
PLEASE PRINT THIS PAGE NOW!