SUMMER MUSIC ACADEMY
REGISTRATION Please fill out both sides of this form, detach and return to your ETM teacher
or complete and mail to ETM, or register online at www.ETMSMA.eventbrite.com. Registration deadline is Wednesday, June 4, 2014.
Parent/Guardian Name Address City, State, ZIP Home Phone Cell Phone E-Mail Address
EDUCATION THROUGH MUSIC
SUMMER MUSIC ACADEMY JULY 7 -31, 2014 MONDAY-THURSDAY
Emergency Contact Name Relationship Emergency Phone
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MEDICAL INFORMATION
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Allergies (write “none” if no allergies) Medications Currently Taken (ETM cannot administer medication)
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Medical Conditions (include ADHD and any other behavioral conditions within the last 3 years. Please write “none” if no medical conditions exist.)
Doctor Name and Number I give my permission for to take part in the ETM Summer Music Academy. I understand that this program takes place at MS 529, 3750 Baychester, Bronx, NY. I understand that my child will be participating in physical, musical activities in the school building under appropriate facilitation of ETM staff members. I agree not to hold Education Through Music, MS 529 or any of their agents responsible in the event of injury to my child. Parent/Guardian Signature
EDUCATION THROUGH MUSIC
122 East 42nd Street, New York, NY 10168 www.ETMonline.org 212-972-4788
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KEEP THE MUSIC PLAYING ALL SUMMER LONG!