Student Information

Student First Namerequired

Student Last Namerequired

Student's Current Schoolrequired

Student's Current Graderequired

Student's T-shirt Sizerequired

Student Experience Level*

Please indicate the student's current level of experience with playing on any instrument.

Beginning (0-1 years of experience) Intermediate/Advanced (1+ years of experience)

How many years of experience do you have playing your intstrument(s)?required

For multiple instruments, please list name of each instrument and number of years of experience playing.

Student Health Concernsrequired

Please list and health concerns and/or allergies. If none, please type "N/A."

Parent Information

Parent 1 First and Last Namerequired

Parent 1 Emailrequired

Parent 1 Cell Phone Numberrequired

Parent 2 First and Last Name

Parent 2 Email

Parent 2 Cell Phone Number

Emergency Contact Information

Emergency Contact First and Last Namerequired

Please list a contact other than the parent(s).

Emergency Contact Cell Phone Numberrequired

Participation Authorization and Release

I hereby request that JSerra Catholic High School ("JSerra") permit my son/daughter identified above to participate in the above referenced activity. I am aware that there may be risks associated with such participation. I, individually and on behalf of my minor child, hereby knowingly and voluntarily assume any and all such risks. Moreover, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I, individually and on behalf of my minor child, agree to indemnify and knowingly and voluntarily release, acquit, and discharge JSerra, and each of its officers, directors, employees, agents, volunteers, and representatives, of and from any and all liability, losses (known or unknown), damages, costs, claims, demands, causes of action and/or expenses, including attorneys' fees, relating to or arising from such participation, including but not limited to personal injury, property damage or wrongful death, unless such claims result from the willful misconduct or gross negligence on the part of the school.

I further authorize JSerra personnel, as agent for the undersigned, to consent on behalf of my son/daughter to any medical treatment (including but not limited to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care) which is deemed advisable by the physician, nurse or other health care practitioner present at or in connection with the above referenced service.

Authorization and Release*

By checking this box and adding your full name in the space below, you agree that you have read and agree to all terms listed.

I have read the above and agree to all terms.

Parent/Guardian Electronic Signaturerequired

Enter full name

Program Fee

PROGRAM FEE: $900.00*
Fee is payable to JSerra and does not include instrument rental, which is estimated at $26 to $75 per month, depending on instrument. All payments are non-refundable.

*Scholarships may be available for families in need (please reach out to Lindsay McCarthy for more information: Lindsay.McCarthy@jserra.org).

Do you have a promo code?*

Yes No

Enter your code here:required

Full-time JSerra Employee?*

Yes No

Employee Coderequired

JSerra Employee Namerequired

Optional Donation*

Would you like to make an additional donation to the JSerra Arts Academy - Middle School Band and Orchestra Program?

Yes No

Please enter donation amount:required

JSerra Catholic High School is a registered 501(c)3 tax exempt organization, Federal Tax ID 33-0901351. Your gift is tax-deductible to the extent allowable by law. Thank you for your support!

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