Camp Year
Grouping for Child
Band Assignment
If installments, enter the remaining balance of the tuition.
Student is Fully Paid?
Which program are you registering for?
Week 2 - JAM Extended Day 7/6-7/10
Student Name
Leo Levine
Student's Email Address
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T-Shirt Size
S
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
TromboneBass
List Other Instrument and/or Multiple instruments here:
Tenor Trombone
Number of Years of Formal Music Training
4
Previous Training in Jazz Improvisation
Yes
Have you been previously enrolled to the JAM Camp?
No
If yes, what year did you enroll to the Camp?
School
School's Name
Albert Einstein Highschool
City
Kensington
State
MD
Grade Entering in Fall 2026
10
Student's Home Information
Street Address
6518 Westmoreland Ave.
City
Takoma
State
MD
Zip
20912
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Laura Goertzel
Parent 1
Parent's Email Address (Primary)(valid email required)
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Parent 2 Name
Additional Email Addresses
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Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Bruce Levine
Contact 1 Relationship
Father
Contact 1 Phone (Camp Hours)
Contact 2 Name
Contact 2 Relationship
Contact 2 Phone (Camp Hours)
All information is True and Correct
- Yes
Payment Plan (Optional/Select Deposit on Tuition Page)
Available payment options
No
Are you interested in a private lesson?
Choose One
Survey Question
How did you hear about the JAM Camps?
Family or Friend
Note other source, including teacher here:
Nestor and Adam
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
Parent Name
Email Address
Relationship to student?
Day Phone
Parent and/or Legal Guardian Information
Parent 1 [P1] and/or Father's Name
[P1] Phone #
[P1] Cell #
[P1] Email Address
Parent 2 [P2] and/or Mother's Name
[P2] Phone #
[P2] Cell #
[P2] Email Address
COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
Are there any conditions that the Jazz Academy of Music should be aware of, such as, Special Needs, ADHD, Asthma, OCD, Emotional Issues, Surgeries, Diseases, or Health Conditions?
If "YES" to question above please list condition(s):
I do hereby verify that the student, to the best of my knowledge, is free from all and and contagious disease(s), is fully immunized and is able to participate fully in the JAM for which he/she is registered.
Has the student been fully immunized? (Select One)
AUTHORIZATION FOR CONSENT
By checking this box you are consenting to treatment should the student appear to be having a life-threatening, breathing or other emergency.
EMERGENCY CONTACT(S)
Name
Relationship
Phone
Name
Relationship
Phone
PHYSICIAN/HEALTHCARE PROVIDER
Doctor
Doctor's Phone #
INSURANCE
Insurance Company
Insurance thru (Policy Holder)
Policy Number
Group Number
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
Parent Name
Email Address
Relationship to student?
Day Phone
Parent and/or Legal Guardian Information
Parent 1 [P1] and/or Father's Name
[P1] Phone #
[P1] Cell #
[P1] Email Address
Parent 2 [P2] and/or Mother's Name
[P2] Phone #
[P2] Cell #
[P2] Email Address
COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
Are there any conditions that the Jazz Academy of Music should be aware of, such as, Special Needs, ADHD, Asthma, OCD, Emotional Issues, Surgeries, Diseases, or Health Conditions?
If "YES" to question above please list condition(s):
I do hereby verify that the student, to the best of my knowledge, is free from all and and contagious disease(s), is fully immunized and is able to participate fully in the JAM for which he/she is registered.
Has the student been fully immunized? (Select One)
EMERGENCY CONTACT(S)
Name
Relationship
Phone
Name
Relationship
Phone
PHYSICIAN/HEALTHCARE PROVIDER
Doctor
Doctor's Phone #
INSURANCE
Insurance Company
Insurance thru (Policy Holder)
Policy Number
Group Number
AUTHORIZATION FOR CONSENT
By checking this box you are consenting to treatment should the student appear to be having a life-threatening, breathing or other emergency.
