Registration Form

EPIC BRASS SUMMER INSTITUTE REGISTRATION FORM


	Date


	Name


	Age


	Instrument


	Address


	City


		State


	Zip Code

Schedule of Events

Registration form

Placement auditions and important information


	E-mail Address


		Phone Number (Required)


	Fax Number


	Medical Insurance Company and Policy Number


	Physicians Name and Telephone Number




		Emergency Contact and Relationship to Participant



	Allergies



			Medications


	Please Send a Finacial Aid Form (Deadline for filling March 1, 2008)


	Please send me information about the AWS Summer Band

		I hereby give permission for my child to receive medical treatment if cannot be reached


	I agree to hold harmless Earl Raney, Epic Brass, Thayer Performing Arts Center, Atlantic Union College, Its Agents, employees, contractors and volunteers from any and all claims sustained while participating in this program


	Name (check if Parent or Guardian)


	A Credit Card Number is required for the online Registration. $50.00 Non-refundable registration fee must accompany each application. You may charge the entire $100.00 tuition.


		Credit Card Number


	Expiration Date


	Name Shown On Card


	Signature__________________________________ _


	Charge Only $50 Dollar Deposit


	Charge entire $100 to my Card

Do not email this form.
Mail or fax this form to:

Fax 1-508-339-6450
Epic Brass Summer Institute
c/o Earl Raney, Director
146 Court Street
Mansfield, MA 02048