Non-Residential Program Registration

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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 25, 2024, will the student be age 18 or over?*
- Yes
- No
Grade in School in 2023-24:
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 Jazz Workshop
- Adventure Music Camp
- Keyboard Explorations I
- Keyboard Explorations II
- Guitar Intensive Workshop
- Adult Chamber Music Workshop
- High School Wind Ensemble Workshop
- Early Childhood Music Program
- Summer Studio Orchestra
- Summer Gamelan Workshop
- Mandolin Workshop – Introductory
- Mandolin Workshop – Intermediate
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 Jazz Workshop Tuition
Adventure Music Camp Tuition
Keyboard Explorations I Tuition
Keyboard Explorations II Tuition
Guitar Intensive Workshop Tuition
Adult Chamber Music Tuition
High School Wind Ensemble Workshop Tuition
Early Childhood Music Program Tuition
Summer Studio Orchestra Tuition
Summer Gamelan Workshop Tuition
Mandolin Workshop – Introductory
Mandolin Workshop – Intermediate
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:
MM slash DD slash YYYY
Parent or Guardian (required if student is under 18 years of age):
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 Parent or Guardian:
Date:
MM slash DD slash YYYY

Save and Continue Later

Non-Residential Program Registration

This form is best filled out on a desktop/laptop.

STUDENT INFORMATION

REGISTRATION INFORMATION for Summer@Eastman Programs

Discounts

PHOTOGRAPHY, SOUND AND VIDEO RECORDING RELEASE

HOW DID YOU HEAR ABOUT THIS PROGRAM?

Medical Information

SIGNATURES