Name: _____________________________________
Email : _____________________________________
Address: _____________________________________
_____________________________________
_____________________________________
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Parent's
Names: _____________________________________
Work Phone: ___________ Cell: ___________
______________________________________
Work Phone: ___________ Cell: ___________
Emergency Contacts (other than parents):
______________________________________
Home Phone: ___________ Cell: ___________
______________________________________
Home 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 SummerJazz Stamford
Mail to: SummerJazz c/o P.O. Box 3595Stamford, CT 06905
See you at SummerJazz!!
