Conservatory Registration Fall 2013

Student Information
Name ____________________________________________ Age ______________ Birthday ___________________________________
Grade ______________ School ______________________________________________________________________________________
Home Address ___________________________________________________________________ Zip Code______________________
Home Phone _____________________________________ Student Email ________________________________________________
Students Conservatory Program(s) (circle)

Junior Strings

Chamber Players

Childrens Chorus

Instrument or Voice Part ________________________________________________________ Years of Experience __________

Private Instructor(s) _____________________________________________________________________________________________
School Music Ensemble(s)____________________________ School Music Conductor(s) _____________________________

Parent/Guardian Information
Parent/Guardian Name(s) _______________________________________________________________________________________
Email(s) for Parent/Guardian ____________________________________________________________________________________
Telephone Numbers (Home, Work, Cell) ________________________________________________________________________
Medical and Emergency Information
Emergency Contact Name __________________________________________ Relationship ______________________________
Contact Phone Numbers ________________________________________________________________________________________
Name of Doctor ____________________________________________________ Doctors Phone Number _________________
Hospital Preference ________________________________________________ Insurance Carrier _________________________
Insurance Policy Number __________________________________________ Member Number _________________________
Allergies/Medications/Medical Conditions ______________________________________________________________________
Minor Release Form
I/We give my/our permission for my/our child ___________________________ to participate in all regular activities of
the Missouri Symphony Society Conservatory program, including, but not limited to, travel in privately owned and
commercial vehicles to performances and activities.
I/We give authorization to supervisory personnel of the Missouri Symphony Society to consent to any medical
attention, treatment, medication, surgery or hospital care rendered, upon the advice of a licensed physician, to
my/our minor son/daughter while under the supervision of such supervisory personnel of the Missouri Symphony
Society.
I/We have medical, health or accident insurance for my/our child.

yes

no

I/We fully and forever absolve and release the Missouri Symphony Society, its members, officers, agents, employees,
volunteers, successors and assigns, and each of them, of and from any and all responsibility, liability or both, for any
and all bodily injuries, damages, or property damage or loss sustained by my/our son/daughter while participating
in any planned activity of the Missouri Symphony Society Conservatory program or traveling to or from
such activities.

This release does not apply to intentional acts or gross negligence on the part of any individual performing service
for the Missouri Symphony Society Conservatory program in connection with any activity, but shall apply to all other
bases of liability.
I/We indemnify the Missouri Symphony Society and each of its members, officers, agents, employees, volunteers,
successors and assigns and hold them harmless from all claims, suits, liabilities and actions of every kind and nature
arising out of injuries to or the death of my/our son/daughter while participating in any planned activity of the
Missouri Symphony Society Conservatory program and for any and all injuries, damages or both, occurring because
of the negligent or intentional acts of my/our son/daughter while engaged in the activity or in transit to and from.
Signature _________________________________________________________________ Relationship __________________________________
Parent or Guardian
Print Name _______________________________________________________________ Date ___________________________________________
Parent or Guardian

Photo Release
I give permission for the Missouri Symphony Society to use photos of my child for publicity purposes. Conservatory
students will not be identified by name.
Signature _________________________________________________________________ Date ___________________________________________

Tuition Payment
Indicate which payment plan your family will be using.
Option 1 We will pay full tuition by August 12, 2013.
Option 2 We will pay 50% by August 12 and the remaining 50% by September 12, 2013.

Childrens Chorus Tuition, $200

Jr. Strings Tuition, $200
Chamber Players Tuition, $225
Subtract $50 if child is participating in both choral and orchestral ensembles
Subtract $20 if child has sibling paying full tuition in either orchestra or chorus
(name of full tuition sibling _______________)
LATE FEE Add $25 if registration form and payment postmarked after
August 12, 2013
TOTAL

$
$
$
$
$
$
$

Registration form and tuition payment must be postmarked by August 12, 2013. Make checks payable to Missouri
Symphony Society. Mail payment and this form to:_
Missouri Symphony Society
Attn Missouri Symphony Conservatory
PO Box 841
Columbia, MO 65205-0841
For office use Check no._____________________________ Payment amount_____________________ Date received________________