Student Name *

First Name

Last Name

Student Cell

Please provide parent cell if student does not have a cell number

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Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

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DD

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Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Cell *

(###)

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Parent/Guardian Home # *

(###)

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Emergency Contact Name *

Please list another contact, other than parent/guardian completing this application

First Name

Last Name

Emergency Contact Cell *

(###)

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Emergency Contact Home # *

(###)

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Instrument(s) *

Select the instrument(s) you wish to play in the ensemble(s)

Violin

Viola

Cello

Bass

Flute

Oboe

Bassoon

Clarinet

Saxophone

French Horn

Trumpet

Trombone

Tuba

Euphonium

Percussion

Guitar

Harp

Piano

Prior Ensemble(s) Participant? *

Please check all SCVYO ensembles you have participated in prior to this enrollment

NONE - New Student

Novae Sinfonia

Symphony Orchestra

Preludes Ensemble

Honors Chamber

Happy Face Club

Summer 2022

Other

Ensemble Enrollment Request(s) *

Please select the ensembles you would like to join. Placement is strictly at the discretion of our music directors.

Preludes Ensemble (beginner)

Honors Chamber (intermediate to advanced)

Symphony Orchestra (intermediate)

Novae Sinfonia (advanced)

School Music Teacher

First Name

Last Name

Private Teacher Name

First Name

Last Name

Private Teacher Phone

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Parent Volunteer Services *

Volunteers help us with our on-going endeavor to bring quality music education and performance opportunities to the youth of our community. Please share your special skills and talents with us. Pick *two* from the following menu:

Join the Board as Parent Rep

Assist in Fundraisers

Performance Supervision

Community Outreach

On-call Volunteer List

Donation in lieu of service ($150 suggested)

Waiver & Photo Release *

I understand that participation in the ensemble(s) sponsored by the SCVYO involves physical activity, and that accidents can occur, and that participants in this or any physical activity can suffer serious injury or death. I further understand that while SCVYO Staff and the SCVYO Volunteer Leaders may be trained in basic first aid and CPR, they are not medical professionals and are not trained to diagnose, monitor or treat chronic or acute medical conditions, whether preexisting or caused by participation in the SCVYO musical education and performance programs. Nevertheless, I, AS THE PARENT/LEGAL GUARDIAN, OF THE ABOVE-MENTIONED MINOR (hereafter “Minor”) AND FOR MYSELF, HEREBY ASSUME THESE RISKS OF PARTICIPATING IN THE SCVYO. In return for allowing Minor to participate, I, on behalf of Minor and for myself, hereby waive, release, and discharge any and all claims for damages for personal injury, disability, death, or property damage of any kind which may hereafter accrue to Minor or myself as a result of his/her participation in this activity. This release is expressly intended to discharge in advance the SCVYO and its employees, agents, and volunteers from and against any and all liability arising out of or connected in any way with Minor’s participation in this activity. THIS WAIVER AND RELEASE WILL APPLY EVEN THOUGH LIABILITY MAY ARISE OUT OF NEGLIGENCE OR CARELESSNESS ON THE PART OF THOSE DISCHARGED INCLUDING THEIR EMPLOYEES, AGENTS, AND VOLUNTEERS, AND INCLUDING GROSS NEGLIGENCE TO THE EXTENT THAT CALIFORNIA LAW PERMITS SUCH WAIVER AND RELEASE. This Waiver and Liability Release shall apply to Minor and myself, as well as any of our heirs, executors, or administrators. I hereby certify that I am the parent or legal guardian of Minor and that I am acting in that capacity. Further, I acknowledge that I have read this document and understand its contents. For the Parent/Guardian: By submission of this waiver of liability, I acknowledge that the SCVYO Foundation sponsors the musical education and performance activities and realize that NO MEDICAL INSURANCE IS PROVIDED. I, the parent/guardian of the above named Minor, hereby approve his/her participation in the above-mentioned activity. Further, I consent to emergency medical treatment for this minor should the need arise. I expect that the activity supervisors will make an effort to contact me, time permitting, before any treatment other than minor first aid, is administered. PHOTO/IMAGE/VIDEO RELEASE: I hereby grant permission to the employees of the SCVYO Foundation to include pictures, images and/or video of my child taken during organization activities, in any future brochures or other publicity developed by the SCVYO Foundation or by the media. I understand that the SCVYO Foundation owns the images and videos and I will not receive compensation for the use of the images. I consent to the Waiver of Liability & Photo Release

Yes

Today's Date *

MM

DD

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