Personal Information

Summer Music Institute
at Western Illinois University
Camp Registration and Payment
Name
First NameLast Name
Cell Number
Area CodePhone Number
Email
example@example.com
Age
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

Grade in Fall
Gender
Director's Name
School
Primary Instrument or Voice
Secondary Instrument or Voice
Application Completed by
Parent Name
Parent Email

T-Shirt Size
Adult Size - Resident Camper ONLY
Resident/ Commuter?
Previous Camper
Private Lesson
Paid directly to the Instructor: $15

Identify the Camp(s) you would like to attend
Week 1 Day Camps - June 11-15, 2018 - Rock's Youth
Week 1 Day Camps - June 11-15, 2018 - Steel Band
Week 2 Camps - June 17-22, 2018 - Choir, Jazz, String, Live Streaming
Week 3 Camps - June 24-29, 2018 - Band, Marching Leadership

If you are recieving a local scholarship (band boosters, women's club, etc.) list it below.
Local Scholarship Awarded by
Scholarship Amount
All scholarships will be deducted once received. An email will be sent with remaining balance due.

Payment Review
Week 1 Rocky's Day Camp
Week 1 Steel Band Camp
Week 2 Camps
Week 3 Camps
Previous Camper Discount
Commuter Camper Discount
Total Due
A receipt will be emailed to you upon submission.
Today's Payment Amount*
prevnext( X )
USD$50 deposit minimum

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