Name: _____________________________________
Email : _____________________________________
Address: _____________________________________
_____________________________________
_____________________________________
_____________________________________
Parent's
Names: _____________________________________
Work Phone: ___________ Cell: ___________
______________________________________
Work Phone: ___________ Cell: ___________
Emergency Contacts (other than parents):
______________________________________
Land Phone: ___________ Cell: ___________
______________________________________
Land Phone: ___________ Cell: ___________
Doctor: _______________________ Phone: _________
Dentist: _______________________ Phone: _________
Note any allergies or restrictions:
_______________________________________
Instrument: ____________________________________
School: ___________________ Grade Completed: ____
Signature of Parent or Guardian:
___________________________ Date: _______
Please make checks
payable to Summer Jazz
Mail to: Summer Jazz c/o STLC, 884 Newfield Ave., Stamford, CT 06905
See you at Summer Jazz!!
