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