Pacific University String Project: Spring Semester Registration Form
Student’s Name: ____________________________________________________
Age: ___________
Grade (in 2015-16 year): _____________
School Name: ________________________________________________________
Parent/Guardian Name(s): ______________________________________________________
Address: _____________________________________________________
_____________________________________________________
Home Number: _________________________ Cell Number:__________________________
Email Address: ________________________________________________________________
Please all that apply (Dates - February 9th to May 5th, 2016):
Beginners
Tues./Thurs. from 4:00 to 4:55 pm
$50.00
Intermediate Groups
Tues./Thurs. from 5:00 to 5:55 pm
$50.00
Prelude Orchestra
Tues./Thurs. from 5:00 to 5:55 pm
$60.00
Rhapsody Orchestra
Tues./Thurs. from 6:00 to 6:55 pm
$70.00
Chamber Orchestra
Tues./Thurs. from 6:00 to 6:55 pm
$70.00
Private Lessons*
Package of 10 Lessons
$80.00
If participating in Intermediate Group, Orchestra or Lessons,
Instrument: ______________________
Emergency Contact Name: _______________________________________________
Emergency Contact Number: _____________________________________________
Relationship: ____________________________________
February 9th to May 5th
String Project Spring Semester 2016
Pacific University String Project: Spring Semester Registration Form
*Private Lesson Make-Up Policy:
1) Student teachers must be notified at least 2 hours prior to scheduled lesson via phone or email.
2) Its the parent’s responsibility to schedule a make up lesson at earliest convenience.
Payment Information:
Checks Made Payable to:
Pacific University String Project
All registration forms and checks should be mailed to (see below) by January 20th, 2015
Pacific University: Music Department
Attn: Dijana Ihas (String Project)
2043 College Way
Forest Grove, OR 97116
Scholarship Need (Circle One):
Yes
or
No
If yes, how much will you be able to pay (indicate the highest amount you can pay): __________
Class Descriptions:
• Beginners
- Requirement: All Twinkle Variations and Theme
• Intermediate Group
- Requirements: All Twinkle Variations and Theme through Long, Long Ago and at least
Music Reading Lesson 10
• Prelude Orchestra
- Requirements: Perpetual Motion and at least Music Reading Lesson 25
• Rhapsody Orchestra
- Requirements: Andantino and Allegretto and above and at least Music Reading Lesson 34
• Chamber Orchestra
- Students who have 2 or more years of playing experience and who pass an audition process
Photography Release
I hereby grant permission to Pacific University String Project to use photographs and images taken at classes and
performances on its website or in its printed materials without further consideration. I understand that my student
may be in one of those photos and I acknowledge Pacific University String Project’s right to crop or treat the
photograph at its discretion. I understand that pictures placed on a web page will be accessible to anyone with
Internet access and may be used in instructional settings. I also understand that NO complete names are posted with
these photos on the website. I have read this release and fully understand the contents. This release shall be binding
upon me and my heirs and legal representatives.
Parent/Guardian’s Signature: ___________________________________________________
Date: __________________________
February 9th to May 5th
String Project Spring Semester 2016
Pacific University String Project: Spring Semester Registration Form
Informed Consent and General Release:
As a condition of participation in learning activities situation on Pacific University property, wherever situated,
Student’s Parent/Guardian on behalf of Student agree as follows:
• Student and Parent/Guardian of Student on Student’s behalf shall jointly share in the responsibility for Student’s
safety and ensure that Student refrain from endangering other who are participating in activities on Pacific
University property;
• Student and Student’s Parent/Guardian on behalf of Student acknowledge that there are inherent dangers in
learning activities outside the elementary, middle school and high school campus environments;
• Should Parent/Guardian of Student become aware of an accident or injury sustained by Student on Pacific
University property, wherever situated, Parent/Guardian agrees to promptly report same to Pacific University Vice
President of Finance and Administration at (503) 352-1621, 2043 College Way, Forest Grove, Oregon, 97116.
• Learning activities situated on Pacific University property are voluntary;
• Student’s Parent/Guardian expressly warrants and represents that Student currently is, and at all times during
which student shall be, covered by health and accident insurance illness associated with the activities in which
Student participates.
• In case of emergence, accident or illness, Student’s Parent/Guardian on behalf of Student, hereby grants
permission for Student to be treated by a professional medical person and admitted to a hospital if necessary, and
Parent/Guardian further agrees to be the party responsible for all medical expenses which are thereby incurred on
Student’s behalf.
Identification and Release Form:
Parent/Guardian of Student on behalf of Student and Student’s heirs and assigns, expressly agrees to indemnify,
defend and hold harmless Pacific University, its trustees, officers, agents, employees, students and volunteers from all
claims, suits, or actions of any nature arising out of Student’s participation in activities situation on University
property, wherever located, other than intentional or grossly negligent acts of the University, its trustees, officers,
employees, students, and/or agents.
By his/her signature below, Parent/Guardian warrants and represents that he/she is the parent or legal guardian of
Student, and that Parent/Guardian assumes full risk for Student’s voluntary participation in activities on Pacific
University property, including but not limited to the general risks enumerated below:
General Risk
• Classroom facilities situated on Pacific University property are designed and equipped for adult use and
frequently contain stairs, railings, windows, flooring, furniture, furnishing, chemicals and potentially hazardous
substances that would not likely be found in elementary, middle school or high school learning environments.
By his/her signature below, Parent/Guardian warrants and represents that he/she has read this informed consent
agreement and understands same and, further, that he/she agrees to be bound by the covenants, representations,
warranties, conditions, indemnification provisions assumptions of risk and consent contained in this consent
agreement, and that the enforceability of provisions affecting liability, indemnification, insurance coverage, and
assumption of risk shall survive the termination of this agreement.
Parent/Guardian’s Signature: ___________________________________________________
Date: __________________________
February 9th to May 5th
String Project Spring Semester 2016