Chamber Music Camp of Portland ~ July 8 - 13, 2012

First and Last Name
Birthdate
Student Email (this is our PRIMARY form of communication. It is your responsibility to notify us if this will not work for you.)
Student Cell
Mailing Address
City, State & Zip
Home Phone
Instrument
Years Played
Musical Groups Student Has Played In
Private Music Teacher
Teacher Phone
School
School Music Instructor
Grade
Parent/Guardian(s) Names(s)
Mailing Address, Phone, Email IF DIFFERENT from Student
Parent Email
Home Phone
Parent/Guardian(s) Cell Phone #(s)
Health Care Provider
Phone
Dentist
Phone
Health Insurance Carrier
Policy #
Allergies or Other Health Concerns
Emergency Contact & Phone IF PARENT CANNOT BE REACHED
Auditions will be held on March 13, 20, 24, 25, 2012 at the University of Portland. First Choice of audition time is:	Tuesday, March 13 evening Tuesday, March 20 evening Saturday, March 24 morning Saturday, March 24 afternoon Sunday, March 25 afternoon
Second choice for audition time is:	Tuesday, March 13 evening Tuesday, March 20 evening Saturday, March 24 morning Saturday, March 24 afternoon Sunday, March 25 afternoon
$30 Audition Fee is due with this application. Payment Method (Tuition fees are due in full by June 1, 2012.)	Check Credit Card (Mastercard/Visa only)--3% fee applies. Please call 503-234-4077 to make secure cc payment.
Camp t-shirt size	Child Small (6-8) Child Medium (10-12) Child Large (14-16) Child X Large (18-20) Adult Small Adult Medium Adult Large Adult XLarge Adult XXLarge

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