Chippewa Valley Jazz Camp

Chippewa Valley
Jazz Camp 2008!

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Print this form and mail with deposit to :

Chippewa Valley Jazz Camp
c/o Bruce Hering
18256 54th Avenue
Chippewa Falls, WI 54729

Part 1: Application

Last Name:

First Name:

Instrument:

Grade Level Next Year:_______

Address:

City/Zip:

e-mail address:

Fees: $150. $50 deposit due with this application and $100 due first day of camp. Deposit is nonrefundable. Registration guaranteed if deposit is received by May 30th.

Part 2: Medical Information/Emergency Transportation

Student's Name:

Parent's Name:

Daytime Phone:(____)

Other Phone:________________________

Insurance Company:

Insurance Policy No.:

Medicines currently taking:

Medical Conditions/Allergies:

I give the Chippewa Valley Jazz Camp staff permission to transport or arrange for transportation to a hospital/clinic if the need arises. All the above information is correct. I understand any inappropriate behavior could result in removal from the camp.

Parent's Signature:

Thank you! We're looking forward to seeing you at the Chippewa Valley Jazz Camp!