Camp Registration Form
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?
JAM Camp 1-5pm (6/29-7/10)
Student Name
Gabrielle Diรฑo
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
XL
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
Keyboard
List Other Instrument and/or Multiple instruments here:
Number of Years of Formal Music Training
Previous Training in Jazz Improvisation
Have you been previously enrolled to the JAM Camp?
No
If yes, what year did you enroll to the Camp?
School
School's Name
test scbhool
City
test
State
tset
Grade Entering in Fall 2026
12
Student's Home Information
Street Address
test
City
test
State
tset
Zip
12345
Phone
Parent and/or Guardian Declaration
Parent 1 Name
test
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Additional Email Addresses
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
tset
Contact 1 Relationship
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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?
No
Survey Question
How did you hear about the JAM Camps?
Website
Note other source, including teacher here:
Medical Form
In which program is the student attending?
JAM Camp 1pm-5pm
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
- Check the box if you are the parent/guardian filling up this form.
Parent Name
tset test
Email Address
Email hidden; Javascript is required.
Relationship to student?
Day Phone
Parent and/or Legal Guardian Information
Parent 1 [P1] and/or Father's Name
tset
[P1] Phone #
[P1] Cell #
[P1] Email Address
Email hidden; Javascript is required.
Parent 2 [P2] and/or Mother's Name
[P2] Phone #
[P2] Cell #
[P2] Email Address
COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION
In the event of an emergency,
when parents or emergency contacts cannot be reached,
the Jazz Academy of Music will forward the
information to emergency technicians and the
student will be transported to the nearest hospital.
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
No
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Yes
Is there a religious objection or medical contradiction why the student is not immunized?
No
Are there any physical conditions that would limit the students ability to participate in physical activities?
No
Is the student on any prescription or over the counter medication?
No
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?
No
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.
Yes
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.
- Agree
EMERGENCY CONTACT(S)
If I/We, the parents/guardians, cannot be reached in
an emergency, please call:
Name
test
Relationship
test
Phone
Name
Relationship
Phone
PHYSICIAN/HEALTHCARE PROVIDER
Doctor
Doctor's Phone #
INSURANCE
Insurance Company
Insurance thru (Policy Holder)
Policy Number
Group Number
Medication Form
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
Email hidden; Javascript is required.
Relationship to student?
Day Phone
Parent and/or Legal Guardian Information
Parent 1 [P1] and/or Father's Name
tset
[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
In the event of an emergency,
when parents or emergency contacts cannot be reached,
the Jazz Academy of Music will forward the
information to emergency technicians and the
student will be transported to the nearest hospital.
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)
If I/We, the parents/guardians, cannot be reached in
an emergency, please call:
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.
- Yes
