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Name:

First Name

Last Name

Gender

Male
Female
Prefer not to answer

Date of Birth (mm/dd/yyyy)

What school do you attend?

Private Lesson Teacher Name (If applicable)

Augmented Combo Instrument

Flute

Horn

Clarinet

None of the Above

Bass Clarinet

Have you been a member of:

9-12 All-County Band
9-12 District/Region Honor Band
9-12 All State Band
Other Auditioned Honors Ensemble (please specify)
None of the Above: Letter of Recommendation Required

A Letter of Recommendation from your current band director or private lesson instructor is only required if you have not been selected for an honors ensemble or have previously participated in the Conservatory Jazz Ensemble. If you require a Letter of Recommendation, please submit by January 7th to Wycliffe Gordon via the Conservatory: consprog@augusta.edu.

This does not guarantee selection into the Conservatory Jazz Ensemble. Decisions will be notified to applicants by 24 hours after the deadline.

I acknowledge the Letter of Recommendation policy

What part do you typically play in your High School Band? [e.g. Clarinet I, Trumpet II, etc.]

First Part
Second Part
No

Parent Name

Parent email

Student Email (if applicable)

Mailing Address

Street Address Line 1

Street Address Line 2

City

State

Zipcode

Parent Cell Phone Number

Student Cell Phone Number (if applicable)

By typing your name below, you agree to the Conservatory Program Code of Conduct.

Respect and adhere to Conservatory Program rules and guidelines outlined by your instructor at the beginning of the semester.
Act in a courteous manner and treat participants, volunteers, staff, and others with respect.
Appropriate language and behavior are expected at all times.
Obey University policies and local, state and federal laws.
Come to rehearsal on time and prepared with required materials.

Photo Release Form

As the parent and/or legal guardian of the Participant, I hereby give the Augusta University, and the Board of Regents of the University System of Georgia, the right and permission to use, reproduce, edit, exhibit, project, display, copyright and/or publish my/my child’s images, likeness, and voice in which I/my child may be included in the whole or in part, developed during participation in the Program/Activity and thereafter, and to circulate the same in all forms and media for any lawful purpose whatsoever. My consent includes, but is not limited to, images, likenesses and recordings that may be deemed to be educational records under the Family Educational Rights and Privacy Act of 1974 (“FERPA”). I understand and agree that my/my child’s image will become part of the Augusta University’s photograph file and that it may be distributed to other organizations or individuals for use in any publications, media, or technology now known of or hereafter developed in the future for any lawful purpose whatsoever without further permission from me. I also understand that I will receive no compensation in connection with the use of my/my child’s image. I hereby waive the right to inspect or approve my/my child’s image or any finished materials that incorporates the image. I further release, discharge, and agree to waive the Augusta University, and the Board of Regents of the University System of Georgia, their licensees, successors, legal representatives and assignees from any liability for violation of any personal or proprietary right that I may have in conjunction with said pictures or images and with the use thereof. I further acknowledge and agree that the Augusta University and the Board of Regents of the University System of Georgia and its members, their officers, agents, and employees shall not be responsible for any of such image, likeness or recording by any third party accessing it through the internet or any other means. Please select an option.

Yes, I consent to the photo release waiver.
No, I do not consent to the photo release waiver.
Type your name in the box below to confirm your choice above.

Authorization for Medical Care and Consent to Participate

I understand that my child is voluntarily participating in an Augusta University program/activity. By signing this form I hereby acknowledge that all information is accurate and current, that any activity restrictions, allergies, and medications are listed on this form, and to the best of my knowledge, my child is capable of participating safely in the program/activity. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program/activity. I agree to notify the program/activity of any changes in my child’s mental, physical, or medical condition before the program/activity begins. I understand that Augusta University does NOT provide medical insurance for my child and that I should consult my child’s physician before allowing my child to participate in this program/activity. In the case of accident or illness, I hereby authorize the program/activity staff to administer or seek medical treatment for my child, as they see fit, including routine first aid care or emergency medical treatment. I hold harmless and agree to indemnify the program/activity, Augusta University, and the Board of Regents from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustained through my child’s participation in such voluntary program/activity.

Consent to Participate in the Augusta University Music Conservatory Jazz Band

I give my child permission to participate in the Augusta University Music Conservatory School Jazz Band. I understand that students are not allowed to wander the Augusta University campus after class, and my child must attend all rehearsals in order to participate in this ensemble. Failure to attend all rehearsals and/or be on time to rehearsals may result in removal from the ensemble without refund. Absences due to emergencies, illness, or conflicts with school band performances are excused.

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