HEAL 2024 SJC Registration

HEAL Center for the Arts

2024 Summer Jazz Camp Registration Form
Name of Student

First NameLast Name
Student Age
Grade Level
Gender
E-mail
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Pronouns
School Attended
Physical Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Instruments played and for how long?
Student T-shirt Size
How did you hear about HEAL's Summer Jazz Camp?
Parent Guardian Information/Emergency Contact
Parent/Guardian Full Name

First NameLast Name
Relationship to Participant
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Authorization for Participant
In case of illness or injury, HEAL Center for the Arts has my permission to procure medical treatment for the above named minor. I understand that HEAL Center for the Arts does not provide medical insurance or reimbursement for medical fees or prescriptions and that I am responsible for any and all fees and charges arising from illness or injury that may occur to the above named during activities with HEAL Center for the Arts.
Physician's Name
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature
Media Release
I hereby grant HEAL Center for the Arts permission to use my image in
photograph(s)/ video(s) in any of its public relation efforts (brochures, newsletters, web site, promotional materials and otherwise) or for any other lawful purpose. I will make no claim or action against or make claim for any fee or compensation for the use of my likeness in any photographs or videos.

If this form is being completed for a person under the age of 18, the signature must be completed by a guardian.
Signature
Are you completing this form for yourself or a minor?
Should be Empty:

HEAL Center for the Arts

Parent Guardian Information/Emergency Contact

Medical Authorization for Participant

Media Release