Name *

First Name

Last Name

Phone *

(###)

###

####

Parent/Guardian Name *

If over 18, use this field for emergency contact.

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Grade Level *

Elementary School

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

College

Have you previously participated in the Conrad O. Johnson Foundation programs? *

None

Summer Music Institute

Regional Youth Orchestra

Other (please specify)

Do you currently take private lessons? *

Yes

No

You auditioning for:

Youth Ensemble (Regional Jazz Band)

Summer Music Institute

Scholarship consideration

Instrument request

Are you available for weekly rehearsals on Sundays (2p–5p)? *

Yes

No

Are you willing to participate in community service and fundraising events (minimum 50% annually)? *

Yes

No

Will you attend all scheduled performances except in emergencies?

Yes

No

What type of technology do you use at home? *

Check all that apply

Desktop (PC)

Desktop (Mac)

Desktop (Other)

Laptop (PC)

Laptop (Mac)

Laptop (Other)

iPad

Android tablet

Kindle or Nook

Chromebook

Smartphone

None

How do you access the Internet at home? *

Broadband (through a cable company hotspot)

DSL (through the phone company)

Dial‐Up (must connect via phone dial)

Cellular service

No Internet Access

Do you have supportive classmates?

Yes

No

I understand that attendance, rehearsal participation, and community service are mandatory components of this program. *

I Agree

I give permission for my child’s image, name, and performances to be used in promotional materials. *

Yes

No