SCOPE Summer Explorations Program - Commack Union Free ...

2013 SCOPE Summer Music Program at CommackLocation: Burr Intermediate SchoolMonday, July 1 - Friday, July 26, 20131 st Period 8:30–9:45am2 nd Period 9:55–11:10am3 rd Period 11:20am–12:35pmMusic Program Registration Form (Students entering grades 4–8)***Parents are responsible for providing an instrument for their child. ***Child’s Name______________________________________ Parent’s Name_________________________________________Current Grade___________ Current School ___________________________Current Teacher________________________Home Address________________________________________________ Email_____________________________________Street Town ZipHome Phone ___________________Cell Phone ( ) ____________________Work Phone ( ) ______________________Local Emergency Contact Name ______________________________________ Relationship__________________________Emergency Phone __________________________Emergency Cell Phone () ____________________________________Physician’s Name/Phone/Medical Needs/Issues _______________________________________________________________*** If your child has a medical condition or allergies, please email the Nurse, Diana Bishop, at dbishop@commack.k12.ny.us orcall 631-858-3621 prior to June 21, 2013.Fee for 1 Music Class = $180.00Fee for 2 Music Classes = $360.00Check #_______________Amount_________________Please Note: The music program runs for one four week session. Each class is 75 minutes in length. Refunds willnot be issued after June 21, 2013. All refunds issued prior to June 21 st will incur a $10.00 processing fee.Music ProgramInstrumental music lessons will be offered to students entering grades 4–8. Students may participate in Band,Orchestra, and Musical Theater/Chorus. Students in grades 6-8 may participate in Jazz Band.Band (Grades 4-8 ONLY) 1 st Period (8:30 – 9:45am) Instrument_______________________Beginner _____Intermediate_____ Percussion (Intermediate only) _____Jazz Band (Grades 6-8 ONLY) 2 nd Period (9:55 – 11:10am) Instrument_____________________Musical Theater/Chorus (Grades 4-8 ONLY) 2 nd Period (9:55 – 11:10am) Check here to register ______Orchestra (Grades 4-8 ONLY)Beginner _____Intermediate_____3 rd Period (11:20am – 12:35pm) Instrument______________________Kindly return the completed registration form and a check/money order made payable to SCOPE, or theCredit Card Authorization Form (see attached) no later than Friday, June 14, 2013 to:SCOPE Education Services100 Lawrence AvenueSmithtown, New York 11787ATTN: Commack Summer ProgramAll printing and copying provided by SCOPE