Non-Res Form Test

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STUDENT INFORMATION

Student's Full Legal Name*

First Middle Last

Student's Preferred Name (if applicable)

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student's Date of Birth:*

Gender*

Female
Male
Undisclosed

Preferred Pronoun

She/her
He/him
They/them
Undisclosed

RACE/ETHNICITY

Colleges and universities are asked by many groups, including the federal government, accrediting associations, college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to answer the following two questions.

Are you Hispanic or Latino?*

Yes
No

Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Email address for program notifications and billing:*

Student contact email address:*

Student contact phone while on campus:*

Please include area code.

Emergency Contact:

Name*

Phone (include area code)*

Relationship*

Is the student a U.S. citizen?*

Yes
No

State of legal residence

Country of citizenship

Type of visa/expiration date

Is the student a permanent resident of the United States?

Yes
No

As of June 28, 2023, will the student be age 18 or over?*

Yes
No

Grade in School in 2022-23:

Name of School and District:

Current NYSSMA Level [if applicable]:

Years of studying instrument:

Name of Private Music Teacher:

Email of Private Music Teacher:

Name of School Music Teacher:

Email of School Music Teacher:

Parent/Guardian #1:

(Student may enter one or both but at least one is required)

Name:*

Phone (include area code):*

Parent/Guardian #2:

Name:

Phone (include area code):

Have you attended the University of Rochester, the Eastman School of Music, or the Eastman Community Music School before?*

Yes
No

If you know your UR Student ID number, enter it here:

Last date of attendance (month/year):

Name when enrolled

First Last

Instrument/Voice Range/Specialty*

Are you a current University of Rochester employee?

Yes
No

If yes, what is your URID?

REGISTRATION INFORMATION for Summer@Eastman Programs

Eastman Community Music School Programs:*

High School Wind Ensemble Workshop
Adventure Music Camp
Keyboard Explorations
Gamelan Workshop
Adult Chamber Music Workshop
Mandolin Workshop – Introductory
Mandolin Workshop – Intermediate
Mandolin for Bowed String Players Workshop

Note: you must be 18+ to apply for "Adult Chamber Music Workshop". Mandolin Workshops are open to grade 6-adult.

Eastman Community Music School Programs for Music Educators:

Must be 18+ to apply. Both programs are free for Music Educators.

Music Educators Wind Ensemble
Music Educators Jazz Ensemble

High School Wind Ensembles Tuition

Adventure Music Camp Tuition

Keyboard Explorations Tuition

Gamelan Workshop Tuition

Adult Chamber Music Tuition

Mandolin Workshop – Introductory

Mandolin Workshop – Intermediate

Mandolin for Bowed String Players Workshop

Total

$0.00

No payment is due at this time. Information about billing/payment will be sent separately once your registration has been processed.

Discounts

- 10% discount for ECMS students enrolled both semesters of 2022-23 school year;

- 25% discount for dependents of qualifying University of Rochester employees upon completion and acceptance of tuition waiver application.

If the student is a dependent of a qualifying University of Rochester employee, the employee must first apply for the tuition waiver through their HRMS page before the discount can be applied to the student’s account.

PHOTOGRAPHY, SOUND AND VIDEO RECORDING RELEASE

Release Consent*

I hereby consent to be photographed and recorded (sound and video) for the Eastman School of Music. The resulting photographs, sound and video recordings may be subsequently used without compensation to me by the Eastman School of Music, the University of Rochester, or third parties for publications (including web sites), advertising, and/or publicity purposes at the discretion of the School’s Communications Office. I waive the right to inspect or approve the finished photograph and/or recording and/or publication use. *Note: Summer@Eastman concerts may be livestreamed and/or video recorded.

Agreed
Opt-Out - You must submit an annual Opt-Out form: www.esm.rochester.edu/community/files/Photo-Opt-Out-Release-1.pdf

HOW DID YOU HEAR ABOUT THIS PROGRAM?

Summer@Eastman website
Summer@Eastman brochure
Summer@Eastman newsletter
Summer@Eastman Facebook page

Online listing, please specify website

Print ad, please specify source

Recommended by (please check one):

School teacher
Private music teacher
Eastman student
ECMS student
Previous Summer student

Medical Information

Any medical conditions, allergies, or dietary restrictions we should be aware of?*

Yes
No

If Yes, describe below:

Does the student need any special consideration on the advice of a physician?*

Yes
No

Does the student need any special consideration on the advice of a psychiatrist, psychologist, or mental health therapist?*

Yes
No

If the student will be requesting reasonable accommodations on the basis of a disability (for accessibility or classroom needs) please visit:

https://summer.esm.rochester.edu/accessibility-and-acommodations/

Will the student be carrying any medications, insulin, epi pens, etc with them during the program?

Or is there anything else medically we should know about the student or their care plan? Please describe below.

All medications must come in separate original labeled containers. Medications must not expire before the end of the session. Prescription medications must be written in the name of the student. All medication (prescription or non-prescription) must be accompanied by a patient-specific written order from a licensed prescriber. Pharmacy labeling on the medication is not sufficient for this purpose as the medication, dosage, and or regimen may have been changed since the pharmacy filled the prescription. This is a NY State requirement.

NOTE: Additional medical documentation might be required depending on New York State requirements.

SIGNATURES

ECMS Payment Agreement: I understand that the University must receive the full amount (as described in the ECMS catalog and website) due less any financial aid on or before the due date as noted on the bill, and that if the full payment is not received by the due date, the University will assess a monthly late payment fee of 1% of the amount past due. I understand that I am responsible for any late payment fee resulting from delays in the delivery of my bill. Payment must be in U.S. dollars. I further certify that should my account not be kept current, I understand the University may curtail my ability to register for future semesters. I acknowledge the University’s right to assess collection and legal fees should my account remain unpaid at the time I leave the University. I understand that I am obligated to pay those fees. I further agree to accept the ECMS refund policies as found on the ECMS website.

Student (required if student is 18 years of age or older):

By checking this box, I acknowledge that the information above is correct to the best of my abilities. I have read, understood, and agree to the ECMS Payment Agreement.

I agree.

Typed Signature of Student:

Date:

Parent or Guardian (required if student is under 18 years of age):