Child’s Name____________________________ M/F (circle) Age _______ D.O.B.___________ School______ Grade completed as of June 2013 _____________ Guardian Name and Number: ________________________________________________ Address ____________________________________________________ City______________________ State________________ Zip ________________ Home Phone # _______________________ Cell Phone # ______________________ E-Mail Address ___________________________
SUMMER MUSIC ACADEMY
Emergency Contact name/relationship______________________ Emergency Contact #______________________________
Want to continue mastering your musical skills this summer? Medical Information Allergies: (please write “none” if no allergies) _________________ Medications Currently taken (ETM cannot administer medication):___________________________________________ Medical Conditions: (including ADHD and any other behavioral conditions within the last 3 years. Please write “none” if no medical conditions exist.) ______________________________________
The ETM Summer Music Academy offers students a month-long exciting opportunity to collaborate with peers from all of ETM partner schools in NYC. Students will participate daily in a variety of fun musical activities including Band, Orchestra, Guitar, Chorus, and Musical Theatre! Don’t let this opportunity pass you by!
Doctor Name and Number:_________________________________
I give my permission for ________________________________ to take part in the ETM Summer Music Academy. I understand that this program takes place at MS 529 One World Middle School. I understand that my child will be participating in physical, musical activities in the school building under appropriate facilitation of ETM staff members. I agree not to hold Education Through Music, MS 529, or any of their agents responsible in the event of injury to my child. Parent/Guardian Signature _________________________________
EDUCATION THROUGH MUSIC 122 E. 42nd St., NY, NY 10168 www.etmonline.org (212) 972-4788
ETM SUMMER MUSIC ACADEMY What is ETM Summer Musical Academy? A wonderful opportunity for students to continue their musical learning over the summer.
Please fill out both sides of page, detach and return to your ETM teacher! ETM SUMMER MUSIC ACADEMY July 8-August 1, 2013, Monday through Thursday
Who can attend ETM Summer Music Academy?
SCHOOL and CURRENT grade: ___________________________
All ETM music students currently in grades 4 through 8. Orchestra and band students must have participated in their school’s ensemble program for at least one year. (Band and Orchestra students must bring their own instruments. Guitars will be provided by ETM.)
Parent /Guardian Name and Phone Number:_______________ ____________________________________________________
How can I attend ETM Summer Music Academy? Interested students should fill out the form on the next page (both sides). You must choose a morning (AM) ensemble (Orchestra, Band, or Guitar). Full day students must also choose an afternoon (PM) session.
Dates, Times, Location MS 529 - One World Middle School 3750 Baychester Avenue Bronx, NY 10466
July 8-August 1, 2013 Mondays Thru Thursdays
PROGRAM SELECTION: Choose one AM session. If full day, also choose a PM session. AM session: 9 am – 12 pm
Musical Theater (PM)
Choral Ensemble (PM)
Guitar Ensemble* (AM)
Guitar Ensemble* (PM)
*You may not choose guitar for both the AM and the PM sessions.
Write Instrument played here Band & orchestra students: write in instrument you play in the box above.
Morning (AM) Session: 9:00 a.m.-12:00 p.m. Full Day Session (AM & PM): 9:00 a.m.-4:00 p.m.
Cost (for all four weeks) Half Day $175 Full Day: $300 (Full day students must pack a bag lunch) Checks or money orders should be made out to
Education Through Music Summer Music Academy.
Credit cards accepted: Visa, Master Card and AMEX. PAYMENT IN FULL DUE BY JUNE 10TH TO GUARANTEE PLACEMENT
PM session: 1 pm – 4 pm
Payment Form (Please Circle One)
Half-Day: $175 Method of Payment ___M.O.
Full-Day: $300 ___Check
Card Number:_______________________________Exp. Date______ Card Holder Name:_______________________________________ Signature______________________________________________