Vermont Rock Music Camp ~

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Choose your Session(s):

*Required Fields

Burlington VT (session 2)
08-04-2008 - 08-08-2008 Cost: $350.00
* this session is full - you will be placed on the waiting list

Total amount of scholarship(s)/financial aid: $

Student Information

* First Name:
* Last Name:
* DOB:
* Sex:	Male Female
* Street:
* City:
* State:
* Zip:
* Does the student have any medical or behavioral conditions that would be helpful for the camp faculty/staff to know about ? Yes: No: If yes, please describe below:

Parent / Legal Guardian Contact Information

* Parent/Legal Guardian Name:

* E-mail:

* Home Phone:

* Mobile/Work Phone:

Instrument(s) / Style(s)

* Primary instrument:
* # of years experience:
Secondary instrument:
# of years experience:
*Primary Style of Interest:
*Secondary Style of Interest:
Is the student a member of a band ?	Yes No
If yes, band name ?

Student Pick-Up and Lunch Permissions

* Check all that apply:

The student will be picked up by a parent/legal guardian.

The student has permission to be picked up by a parent/legal guardian of another student.

The student has permission to leave camp at day’s end unsupervised.

The student has permission to leave the camp premises unsupervised during lunch break.

Note: Students will be required to check out with the appropriate staff member at the end of each day and during lunch (if leaving). Vermont Rock Music Camp LLC shall not be held responsible or liable for the well being of the student during the time the student is not on the camp premises.

Additional Comments:

Terms of Agreement

I confirm that the information provided above is true.

I confirm that the above form has been completed by a parent or legal guardian of the student.

I agree that Vermont Rock Music Camp LLC will not be held accountable for theft or damage of personal property.

I agree that Vermont Rock Music Camp LLC will own the copyright in sound recording and underlying composition for all songs produced for the Rock Camp compact disc/digital download.

I grant Vermont Rock Music Camp LLC permission to publish photographs/video of the student at camp for promotional purposes.

I have read and accept the Terms of Agreement.

Parent/Legal Guardian name: