PACIFIC MUSIC CAMPS         
  •             Junior Band & Orchestra
  •             Senior Band, Orchestra, & Choir
  •             Pacific Music Theatre Camp
  •             Senior Piano Camp
  •             Brubeck Institute Jazz Camp
  •             Pacific Music Business Camp

            Camper Application

 
Parent Information
     Parent/Guardian #1  
* First Name 
* Last Name 
     Parent/Guardian #2  
  First Name   Last Name 
     Contact Information  
* Mailing Address 
  Address Line 2 
* City 
* State 
* Zip 
* Home Phone 
xxx-xxx-xxxx 
  Cell Phone 
xxx-xxx-xxxx 
  Work Phone 
xxx-xxx-xxxx 
  Work Extension 
  Parent/Guardian 
Email Address 
  IMPORTANT: Student/Parent Information Packet will be E-MAILED to the email address listed above.

Please add the following addresses to your email address book:
musiccamp@pacific.edu
sperdicaris@pacific.edu



Other Information
* How did you find out about our music camps? 
  If other, specify 


Emergency Information
  
If Parent/Guardian not available, contact: 
  First Name 
  Last Name 
  Relationship
 
  Phone 
(xxx)xxx-xxxx 
  
Family Doctor's Information 
  First Name 
  Last Name 
  Phone 
(xxx)xxx-xxxx 
  Address 
  Address Line 2 
  City 
  State 
  Zip 


Insurance Information
* Insurance Carrier 
* Group Number 
* Billing Address 
  Billing Address Line 2 
* City 
* State 
* Zip 
* Policy Holder (member) 
* Membership Number 


Registered Camper(s)
Click below to register a camper(s).



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