Youth Orchestra Registration – Philharmonic Society of Belleville

Student's Name?

First

Last

Students's date of birth

MM/DD/YYYY

Parent/Guardian Name

First

Last

Parent/Guardian Phone

Parent/Guardian Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Alternate Emergency Contact Name

First

Last

Alternate Emergency Contact Phone

Allergies or other important medical information:

Instrument & Chair

How many years of experiance does the student have with the above instrument?

Number of Years with BPYO

Please list any other insruments the student plays and years played?

Please list any other Ensembles or groups your student is involved in.

Student's School?

School Grade in Fall?

Music Instructor?

Music Instructor Phone Number?

How did you find out about BPYO?

Waiver Of Liability

Clear Signature

I have completed the health history to the best of my knowledge. The person herein described has permission to engage in all activities. I consent for myself or (for a minor participant) my child to receive such medical treatment as deemed necessary in an emergency and to assume liability for any medical expenses. Should a medical emergency arise in the case of a minor, I understand BPS staff and volunteers will make reasonable efforts to contact me or my designated alternate at the phone numbers I have given. I/we release the staff, volunteers, and the Belleville Philharmonic Society (BPS) from any liability arising from participation in the Belleville Philharmonic Youth Orchestra. Parents of youth – I/we further understand and agree that I/we assume full responsibility for any loss or damage to property or bodily injury to others caused by the participant, whether by accident or intent. I/we also understand that if the behavior of this participant becomes inappropriate, I/we will be responsible for immediate transportation home. MEDIA PERMISSION When participating in Belleville Philharmonic activities, I may be photographed for print, videotaped, or electronically imaged. Images and/or videos may be used in promotional materials, news releases, and other published formats for the Belleville Philharmonic Society and will be the sole property of the organization.

I agree to the following charge:

First Student Registration Fee – $75.00
Additional Student Registration Fee (in same household as first) – $60.00
Prorated Registration Fee (after december 2024) – $50.00

Convenience Fee

Price: $3.00

This fee covers the cost of credit card procesing.

Additional Donation

Your additional donation can ensure that every child, regardless of their background, has the opportunity to experience the joy of making music together. It can provide scholarships for those in need, purchase new instruments, and fund enriching experiences that will shape their musical journey for years to come.

Minimum Price: $1.00

Total

$0.00

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