SCVYO SUMMER CAMP 2017
AUDITION & REGISTRATION APPLICATION

SEE SUMMER CAMP DETAILS HERE

PAY SUMMER FEES HERE

ORDER SCVYO TEE SHIRT HERE

STUDENT INFORMATION
Student Name
Student Name
Date of Birth *
Date of Birth
Student Cell
Student Cell
PARENT/GUARDIAN INFORMATION
Parent/Guardian *
Parent/Guardian
Address *
Address
Parent Cell *
Parent Cell
Parent Home *
Parent Home
Emergency Contact *
Emergency Contact
Emergency Cell *
Emergency Cell
Emergency Home *
Emergency Home
Volunteers help us in 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.
STUDENT SCHOOL & MUSICAL EDUCATION
School attending for the 2016-2017 academic year
What grade was student enrolled August 2016 - June 2017
School Music Teacher
School Music Teacher
PRIVATE TEACHER INFORMATION
Please note that all students should have a private instructor in addition to their school music teacher.
Private Teacher Name
Private Teacher Name
Private Teacher Phone
Private Teacher Phone
Please indicate the primary SCVYO ensemble student was enrolled in during the Spring 2017 semester. Students who participated in an SCVYO ensemble during the Spring 2017 semester do not need to audition for Summer Session.
NEW STUDENTS, ONLY: Please select summer audition request. Music Directors will make placement strictly based on skill level.
CHILD'S HEALTH INFORMATION
Name on Insurance Card *
Name on Insurance Card
e.g., Anthem Blue Cross, Kaiser, etc.
Primary Physician *
Primary Physician
Physician Phone *
Physician Phone
Immunizations Current? *
PLEASE USE THE DROP DOWN MENU to indicate if your child has any of the listed health issues? Use the blank box below to describe medical concerns and treatment (eg, food or environmental allergies, etc).
1. eg: allergy, reaction, symptoms, treatment Please type "NONE" if there are no health/psychiataric concerns.
Please list all medications and doseage requirements your child needs while at Lions Camp. An SCVYO staff member will keep medications in a secured lock-box and administer required medications per instructions provided by parent/legal guardian. Campers requiring the use of an asthma inhaler will be permitted to keep this in their possession at all times. Please type "NONE" if there are no medication requirements.
WAIVER OF LIABILITY & PHOTO RELEASE
Waiver & Photo Release *
I understand that the above-named activity, sponsored by the SCVYO Foundation, involves physical activity, and that accidents can occur during the above-named activity, 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 Foundation 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 above-named activity. 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 ABOVE-MENTIONED SPECIAL EVENT. 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 Foundation 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 above-named activity 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 RELEASE: I hereby grant permission to the employees of the SCVYO Foundation to include pictures 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
Notify SCVYO *
I understand in order to complete this application I must email Bess Knight, Executive Director, at info@scvyo.org to confirm my request for an audition appointment.
Today's Date *
Today's Date
Please follow this link to place your tee shirt order.
http://