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Jazz Camp Scholarship Application
Kuumbwa Jazz Camp 2013
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Student Information
Student Name
*
First
Last
Birth Date
*
Gender
*
Male
Female
Student Address
*
Street Address
City
Zip / Postal Code
Student Phone
Student Email
We primarily contact all applicants and parents by e-mail. If you do not have an e-mail address that you check regularly please indicate in the notes the best way for us to contact you.
Instrument
*
If multiple instruments, please just list instrument to be played at camp.
Years Played
*
Is the student currently in a school music program?
*
Yes
No
Current Band Director / Choir Instructor
Band Director - phone or email
Does the student have a private music instructor?
*
Yes
No
Private Instructor
Private Instructor - phone or email
School Enrolling in for 2013-2014
*
Grade entering Fall 2013
*
Select One
8th grade
9th grade
10th grade
11th grade
12th grade
other
Parent/Guardian Information
Parent/Guardian Name
*
First
Last
Is the parent's address the same as the student's?
*
Yes
No
Parent/Guardian Address
*
Street Address
City
Zip Code
Parent Phone
*
Email
We primarily contact all applicants and parents by e-mail. If you do not have an e-mail address that you check regularly please indicate in the notes the best way for us to contact you.
Emergency Contact
Emergency Contact's Name
*
First
Last
Emergency Phone
*
Relationship to camper
*
Financial Information
You may also complete, print, and fax or mail this form to: Kuumbwa Jazz 320-2 Cedar Street Santa Cruz, Ca 95060 Fax: (831) 427-3342 Phone: 831-427-2227
Has camper ever received a scholarship from KJC?
*
Yes
No
Total number of dependants:
*
Total family annual income:
*
Estimate of what I can pay towards fee:
*
Please Note: This year, most scholarship recipients will be required to pay a minimum of $100.
How will you pay for the tuition if a balance is due?
*
Credit Card (Master Card or Visa only)
Check
Credit Card Number
We will notify you on the status of the scholarship application before any charges are run on the card.
Exp Date
Security Code
*located on the back side of the card
Student Essay
To be completed by the student.
How did you hear about the camp?
*
Select One
Kuumbwa Email
School Music Teacher
Private Music Teacher
Family Member
Past Camper
Newspaper Ad
Kuumbwa Website
Other
Please tell us why you are interested in attending the Kuumbwa Jazz Camp. What do you hope to learn and achieve? What special quality do you have that will contribute to the positive learning environment of Jazz Camp? Tell us how long you’ve been playing and where you do most of your playing, such as in school band, church, with family, on your own, or any other environment.
This portion can be emailed to melody@kuumbwajazz.org or faxed to 831.427.3342
Do you have more to add? Let us know here!
