7/28/2019 Registration Form F13

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Student Information

Name ___________________________________________ Age _____________ Birthday ________________________________

Grade _____________ School ___________________________________________________________________________________

Home Address __________________________________________________________________ Zip Code ___________________Home Phone ____________________________________ Student Email _____________________________________________

Students Conservatory Program(s) (circle) Junior Strings Chamber Players Childrens Choru

nstrument or Voice Part _______________________________________________________ Years of Experience _______

Private Instructor(s) __________________________________________________________________________________________

School Music Ensemble(s) ___________________________ School Music Conductor(s) __________________________

Parent/Guardian Information

Parent/Guardian Name(s) ____________________________________________________________________________________

Email(s) for Parent/Guardian _________________________________________________________________________________

Telephone Numbers (Home, Work, Cell) _____________________________________________________________________

Medical and Emergency Information

Emergency Contact Name _________________________________________ Relationship ___________________________

Contact Phone Numbers _____________________________________________________________________________________

Name of Doctor ___________________________________________________ Doctors Phone Number ______________

Hospital Preference _______________________________________________ Insurance Carrier ______________________

nsurance Policy Number _________________________________________ Member Number ______________________

Allergies/Medications/Medical Conditions ___________________________________________________________________

Conservatory Registration Fall 201

Minor Release Form

/We give my/our permission for my/our child ___________________________ to participate in all regular activities ofhe Missouri Symphony Society Conservatory program, including, but not limited to, travel in privately owned andommercial vehicles to performances and activities.

/We give authorization to supervisory personnel of the Missouri Symphony Society to consent to any medicalttention, treatment, medication, surgery or hospital care rendered, upon the advice of a licensed physician, to

my/our minor son/daughter while under the supervision of such supervisory personnel of the Missouri Symphonociety.

/We have medical, health or accident insurance for my/our child. yes no

/We fully and forever absolve and release the Missouri Symphony Society, its members, ocers, agents, employolunteers, successors and assigns, and each of them, of and from any and all responsibility, liability or both, for nd all bodily injuries, damages, or property damage or loss sustained by my/our son/daughter while participatin

n any planned activity of the Missouri Symphony Society Conservatory program or traveling to or from

uch activities.

7/28/2019 Registration Form F13

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This release does not apply to intentional acts or gross negligence on the part of any individual performing servicor the Missouri Symphony Society Conservatory program in connection with any activity, but shall apply to all ot

bases of liability.

/We indemnify the Missouri Symphony Society and each of its members, ocers, agents, employees, volunteersuccessors and assigns and hold them harmless from all claims, suits, liabilities and actions of every kind and natrising out of injuries to or the death of my/our son/daughter while participating in any planned activity of the

Missouri Symphony Society Conservatory program and for any and all injuries, damages or both, occurring becauof the negligent or intentional acts of my/our son/daughter while engaged in the activity or in transit to and from

ignature ________________________________________________________________ Relationship ______________________________

Print Name ______________________________________________________________ Date _______________________________________

Photo Release

give permission for the Missouri Symphony Society to use photos of my child for publicity purposes. Conservatotudents will not be identied by name.

ignature ________________________________________________________________ Date _______________________________________

Parent or Guardian

Parent or Guardian

Tuition Payment

ndicate which payment plan your family will be using.

Option 1 We will pay full tuition by August 12, 2013.

Option 2 We will pay 50% by August 12 and the remaining 50% by September 12, 2013.

Childrens Chorus Tuition, $200 $

Jr. Strings Tuition, $200 $

Chamber Players Tuition, $225 $

Subtract $50 if child is participating in both choral and orchestral ensembles $

Subtract $20 if child has sibling paying full tuition in either orchestra or chorus(name of full tuition sibling _______________)

$

LATE FEE Add $25 if registration form and payment postmarked afterAugust 12, 2013

$

TOTAL $

Registration form and tuition payment must be postmarked by August 12, 2013. Make checks payable to Missouymphony Society. Mail payment and this form to:

or oce use Check no.____________________________ Payment amount ____________________ Date received ____________

Missouri Symphony SocietyAttn Missouri Symphony ConservatoryPO Box 841Columbia, MO 65205-0841