2018 Music Camps and Workshops Registration Fill out the form below to register for one of the Academy's music camps/workshops. Registration for Camp/Workshop I would like to register for * - Select -Showing Off Musical Theatre Workshop - $269Summer Chamber Music - $199Playing Together Piano Camp - $199Beginning Broadway Musical Theatre Workshop - $199 Parent/Guardian Information First and Last Name * Home Address * City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Email Address * This is the email address to which all camp-related email will be sent to. To ensure delivery of these messages, please add: acad_music@lawrence.edu to your email contact list. Verify Email Address * Preferred Phone Number * Format ex. 9205551212 Home Cell Home or Cell * Place of Employment * Work Phone Number * Format ex. 9205551212 Parent/Guardian Information First and Last Name Is the home address the same as above? - None -YesNo Home Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Email Address This is the email address to which all camp-related email will be sent to. To ensure delivery of these messages, please add: acad_music@lawrence.edu to your email contact list. Verify Email Address Preferred Phone Number Format ex. 9205551212 Home Cell Home or Cell Place of Employment Work Phone Number Format ex. 9205551212 Camper Information First and Last Name * Gender * Male Female Birthdate * Year19992000200120022003200420052006200720082009201020112012 Year MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day School (2018-19 academic school year) * Grade (2018-19 academic year) * Are you interested in performing a solo in the showcase performance? * - Select -YesNo Instrument * Emergency Contact The emergency contact must be someone who is not the parent/guardian. First and Last Name * Relationship to Camper * Phone number to be used in the event of an emergency * Format ex. 9205551212 Repertoire Information Most Current Solo Piece * Current Scale Book * Current Etude Book * Past chamber ensemble repertoire * Private or School Teacher Name * Private or School Teacher Phone Number * Format ex. 9205551212 Private or School Teacher Email * Number of Years of Piano Lessons * Most Current Repertoire * Current Method Book * Piano Teacher Name * Piano Teacher Phone Number * Format ex. 9205551212 Piano Teacher Email * I learn piano music * mostly by reading mostly by listening I learn piano music * quickly slowly What is your ensemble experience? Have you played duets before? * Comments on Repertoire Doctor Information Name of Physician or Clinic * Physician's Phone Number * Format ex. 9205551212 Name of Dentist * Dentist's Phone Number * Format ex. 9205551212 Name of Insurance Company * Policy Number * Policy Holder's Name * Group Number * Health Information Date of last Tetanus shot * Please list any allergies, medications, asthma, diabetes, epilepsy, seizures, etc. Please put N/A if there are no concerns * Does your child have any learning or behavioral needs? * Yes No If so, please list needs or accommodations: * Medical Treatment Consent While attending a Lawrence Academy of Music camp, we must secure your consent for medical treatment or medication distribution and for the use of medical devices. Emergency medications such as inhalers, bee sting kits, or insulin may be kept with the student. I give permission for a Lawrence employee to administer ibuprofen or acetaminophen for headache, menstrual cramps, etc. * Yes No Medication Choices * Ibuprofen Acetaminophen I give permission for a Lawrence employee to administer the following medication prescribed by my child's physician. * Yes No/Not applicable All medications must be in a medicine bottle labeled with the camper's name, doctor's name and phone number, medication name, and dosage. All medications will be stored by camp staff. Name of Medication * Prescribing Physician * Physician's Phone Number * Format ex. 9205551212 Days to be taken * Dosage of medication * How is it taken? * When administered * Special Instructions * Please put N/A if there are none. I authorize my child to participate in the Lawrence Academy of Music summer camp. In the event that I cannot be reached in an emergency, Lawrence has my permission to arrange care and transportation for my child to a health care facility/physician * Yes No Electronic Signature Of Parent or Legal Guardian * Type your name here to authorize the health information and medical treatment consent. Assumption of Risk and Release of Liability This document affects your legal rights - read it carefully. I have applied to participate in the Lawrence Academy of Music program described as the 2018 Musical Theatre Workshop Beginning Broadway during the period July 23-27, 2018. I acknowledge that the Program is voluntary and may involve certain risks, including those described below. I understand that the Program involves, among other activities, rehearsing, performing, engaging in recreation and, if applicable, traveling off campus and residing in student dormitories. I acknowledge that these activities present certain inherent risks beyond Lawrence University’s control. I choose to participate in the Program understanding its associated risks, and I knowingly and voluntarily assume all risks of injury, illness, death or damage to or loss of my property that may occur while rehearsing, performing, traveling, engaging in recreation or any activities arising out of or related to the Program. My participation in the Program is voluntary, and I understand that I may discontinue my participation at any time in light of the risks I am assuming. I hereby forever release Lawrence University, its trustees, officers, employees, and agents (the “Released Parties”), from liability for any negligent act or omission arising from my participation in the Program, including related costs, damages, claims or assertions to which I or my family, estate, or heirs may claim against the Released Parties. This Assumption of Risk and Release of Liability shall be construed in accordance with the laws of the State of Wisconsin, which shall be the forum for any lawsuits filed under or incident to this Release or the Program. This document affects your legal rights - read it carefully. I have applied to participate in the Lawrence Academy of Music program described as the 2018 Chamber Music Odyssey Camp during the period July 9-13, 2018. I acknowledge that the Program is voluntary and may involve certain risks, including those described below. I understand that the Program involves, among other activities, rehearsing, performing, engaging in recreation and, if applicable, traveling off campus and residing in student dormitories. I acknowledge that these activities present certain inherent risks beyond Lawrence University’s control. I choose to participate in the Program understanding its associated risks, and I knowingly and voluntarily assume all risks of injury, illness, death or damage to or loss of my property that may occur while rehearsing, performing, traveling, engaging in recreation or any activities arising out of or related to the Program. My participation in the Program is voluntary, and I understand that I may discontinue my participation at any time in light of the risks I am assuming. I hereby forever release Lawrence University, its trustees, officers, employees, and agents (the “Released Parties”), from liability for any negligent act or omission arising from my participation in the Program, including related costs, damages, claims or assertions to which I or my family, estate, or heirs may claim against the Released Parties. This Assumption of Risk and Release of Liability shall be construed in accordance with the laws of the State of Wisconsin, which shall be the forum for any lawsuits filed under or incident to this Release or the Program. This document affects your legal rights - read it carefully. I have applied to participate in the Lawrence Academy of Music program described as the 2018 Piano Odyssey Camp during the period July 9-13, 2018. I acknowledge that the Program is voluntary and may involve certain risks, including those described below. I understand that the Program involves, among other activities, rehearsing, performing, engaging in recreation and, if applicable, traveling off campus and residing in student dormitories. I acknowledge that these activities present certain inherent risks beyond Lawrence University’s control. I choose to participate in the Program understanding its associated risks, and I knowingly and voluntarily assume all risks of injury, illness, death or damage to or loss of my property that may occur while rehearsing, performing, traveling, engaging in recreation or any activities arising out of or related to the Program. My participation in the Program is voluntary, and I understand that I may discontinue my participation at any time in light of the risks I am assuming. I hereby forever release Lawrence University, its trustees, officers, employees, and agents (the “Released Parties”), from liability for any negligent act or omission arising from my participation in the Program, including related costs, damages, claims or assertions to which I or my family, estate, or heirs may claim against the Released Parties. This Assumption of Risk and Release of Liability shall be construed in accordance with the laws of the State of Wisconsin, which shall be the forum for any lawsuits filed under or incident to this Release or the Program. This document affects your legal rights - read it carefully. I have applied to participate in the Lawrence Academy of Music program described as the 2018 Musical Theatre Workshop Showing Off during the period June 25-29, 2018. I acknowledge that the Program is voluntary and may involve certain risks, including those described below. I understand that the Program involves, among other activities, rehearsing, performing, engaging in recreation and, if applicable, traveling off campus and residing in student dormitories. I acknowledge that these activities present certain inherent risks beyond Lawrence University’s control. I choose to participate in the Program understanding its associated risks, and I knowingly and voluntarily assume all risks of injury, illness, death or damage to or loss of my property that may occur while rehearsing, performing, traveling, engaging in recreation or any activities arising out of or related to the Program. My participation in the Program is voluntary, and I understand that I may discontinue my participation at any time in light of the risks I am assuming. I hereby forever release Lawrence University, its trustees, officers, employees, and agents (the “Released Parties”), from liability for any negligent act or omission arising from my participation in the Program, including related costs, damages, claims or assertions to which I or my family, estate, or heirs may claim against the Released Parties. This Assumption of Risk and Release of Liability shall be construed in accordance with the laws of the State of Wisconsin, which shall be the forum for any lawsuits filed under or incident to this Release or the Program. By checking this box I agree to the Assumption of Risk and Release of Liability. I consent * Academy Camp Guidelines Please read the Academy Camp Guidelines. By checking this box, I agree to follow all of the Academy Camp Guidelines and accept responsibility for all charges and fees that are incurred. Camp Guidelines 3 * How did you hear about Lawrence Academy of Music? * CAPTCHA This question is included to prevent automated spam submissions; it is not presented to logged-in users. Submit
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