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