Harmony summer camp application

This registration is for Harmony summer camp which takes place June 20-24, from 9am-12pm at Riverview Elementary. Camp is free and open to all Harmony students!

Student Details

GTCYS wants to get to know your student! Personal demographic information collected in this form (gender, race, etc.) is used for data tracking purposes only.

Student Name*

First Last

Student instrument:*

Grade in 2021-22:*

Please list the grade this student was in during the 2021-22 school year (this current year).

School in 2022-2023*

Please enter the name of the school that this student will be attending the upcoming school year.

Student birth date:*

Student gender:*

Boy
Girl
Nonbinary

Student pronouns:*

He/him
She/her
They/them

Student race/ethnicity*

We collect confidential information about students’ race/ethnicity to help measure progress toward GTCYS' diversity and equity goals, inform our programming, and report to philanthropic funders who request it.

For this particular purpose, please select the category with which this student most closely identifies. We understand that many students may identify with more than one race or ethnicity. If you are more comfortable, please select “other” and describe the student's race(s). Thank you.

White or Caucasian
Black or African American
Asian or Asian American
Hispanic or Latinx
Native American or Alaska Native
Native Hawaiian or Pacific Islander

If you would like to provide any other details about this student's race, please enter it here:

For example:
-White or Caucasian: If this student is Middle Eastern or Jewish and wishes to specify.
-Black or African American: If this student wishes to list a specific diasporic community.
-Asian or Asian American: If this student wishes to list a specific community.
-Native American or Alaska Native: If this student wishes to list a specific tribal affliation.

Primary Phone*

Please include the primary phone number to contact your family. This should not be a student's cell phone number.

Parent/Guardian Details

Parent/Guardian 1 Name*

First Last

Parent/Guardian 1 Phone*

Parent/Guardian 1 Email*

This will be GTCYS' primary mode of communication with you. Please enter a valid email.

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State ZIP Code

Does the student live with two Parents/Guardians?*

Clicking yes will allow you to complete information for Parent/Guardian 2.

Yes
No

Parent/Guardian 2 Name*

First Last

Parent/Guardian 2 Phone*

Parent/Guardian 2 Email*

This will be GTCYS' primary mode of communication with you. Please enter a valid email.

Enter Email Confirm Email

Have additional Parent/Guardian information?*

Clicking yes will allow you to enter the name and contact information for an additional Parent/Guardian that does not live with the student or lives with the student part time.

Yes
No

Parent/Guardian 3 Name*

First Last

Parent/Guardian 3 Phone*

Parent/Guardian 3 Email*

This will be GTCYS' primary mode of communication with you. Please enter a valid email.

Enter Email Confirm Email

Parent/Guardian 3 Address

Enter parent/guardian 3 address if the student lives with this parent/guardian part time.

Street Address Address Line 2 City State ZIP Code

Medical Information & Emergency Contact

This information is required to support the health and safety of GTCYS students at all GTCYS activities, and it will be kept confidential.

Please be forthright. Disclosing complete and accurate information is in your student's best interest so we can support their success in GTCYS.

Health Insurance Company

Health insurance information is not required, but helpful for GTCYS to have on file in case of emergency.

Health Insurance Details (ID number, group number, and/or subscriber)

Please include the name and phone number of an individual GTCYS can contact if parents/guardians listed above cannot be reached:

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Relationship to Student*

Food Allergies and Dietary Restrictions*

GTCYS will not provide any snacks or other food this summer; however, this information is helpful to have on file in case of emergency.

None
Peanut Allergy
Gluten Allergy
Dairy Allergy
Other

Other (please describe):*

Please list all medications that the student requires, including purpose, name, dosage, and frequency. Should any of these be kept with the student? Do any require administration on an emergency basis? If so, describe.*

If this does not apply, please enter "none."

Please describe any medical conditions including any physical, emotional, behavioral, or mental health conditions. Please be specific.*

If this does not apply, please enter "none."

Will this student be fully vaccinated by Monday, June 20?*

Fully vaccinated means it has been two weeks since receiving the second dose of the Pfizer/Moderna vaccine, or one week since receiving the Janssen vaccine.
This information will guide GTCYS’ masking policy and COVID protection protocols for summer programs.

Yes
No
Prefer not to say

Release and Indemnification Agreement*

THIS RELEASE AND INDEMNIFICATION AGREEMENT (the “Agreement”) is entered into between me and the Greater Twin Cities Youth Symphonies (“GTCYS”) in connection with the 2022 GTCYS Summer Camp.

I, the parent and/or legal guardian of the student above, wish to have my student participate in GTCYS programs during Summer 2022. I acknowledge that although GTCYS is taking steps to promote the health and safety of students, there are still risks of having my student participate, including the risk of contracting and spreading COVID-19. I have been given sufficient opportunity to ask questions and obtain information about the programs and measures being taken to promote health and safety. I understand that my student is free to withdraw from participation at any time. My contact information is included in this form.
I, the parent and/or guardian, agree that at my sole cost and expense, I will release and indemnify, protect and hold GTCYS harmless against and from any and all damages, losses, liabilities, obligations, claims, costs and expenses (including, without limitation, attorney fees and court costs) of any kind or any nature whatsoever arising in whole or in part out of my child’s participation in GTCYS during the 2021 – 2022 season. I enter into this Agreement without reservation of any kind except for liabilities arising out of any intentional wrongful acts on the part of GTCYS, its directors and employees.

Media Disclaimer

By participating in GTCYS, you give permission for your student's name and likeness to be used in any print, digital, or other promotional materials created by GTCYS or its program partners.

Name

This field is for validation purposes and should be left unchanged.

Greater Twin Cities Youth Symphonies Mark Russell Smith, Artistic Director

2022 Harmony Summer Camp Registration

Student Details

Parent/Guardian Details

Medical Information & Emergency Contact

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