Eastman Leadership Development retreat Student Registration Form

Student Information

Student preferred name (if applicable)

Student preferred pronouns:

Please add which pronouns you prefer (if you would like to share)

Student Date of Birth(Required)

Student Gender(Required)

Gender Information (optional)

Federal guidelines mandate that we collect data on the legal sex of all applicants. If you would like the opportunity, you may also share more about your gender identity here:

Student/Parent or Guardian Contact Email(Required)

We will send all communication regarding the retreat to this address.

Student Contact Phone(Required)

Student School(Required)

Student Community Music School (if applicable)

Student's School Music Educator(Required)

Music Educator's Email

Student's Instrument/Voice Part(Required)

e.g. Trumpet, Viola, Soprano, etc.

Student's School Music Leadership Role(s)

Please include any roles you would like to share (e.g. Tri-M Music Honor Society Treasurer, Choir President, Section Leader, etc.)

Parent/Legal Guardian Name(Required)

Parent/Legal Guardian Phone(Required)

Additional Emergency Contact Name(Required)

Emergency Contact Relationship(Required)

Emergency Contact Phone(Required)

Please enter any dietary needs or restrictions.(Required)

Lunch will be provided to all who attend the retreat, including educators.

If other, please specify:

Race/Ethnicity

Colleges and universities are asked by many groups, including the federal government, accrediting associations, college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to answer the following two questions.

Photography, Sound and Video Recording Release

How did you hear about this program?

Please cite who recommended the retreat:

Which website did you find the information?

E.g. Eastman School of Music, Institute for Music Leadership, etc.

Please cite the social media source:

E.g. @eastman.school, @eastmaniml, etc.

If other, please cite the source:

Signatures

Typed Signature of Student:(Required)

Date(Required)

Typed Signature of Parent/Guardian:

Date

Please select your payment method(Required)

If you are unsure if your school is paying your registration fee, please feel free to email jdunn@esm.rochester.edu for more information.

Institution to Invoice for Registration(Required)

Teacher Email Address for Invoice(Required)

We will send an electronic invoice to your listed primary email address to accept credit card payments. Please contact jdunn@esm.rochester.edu with any questions.