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Performance Academy Application 2001

(Print and mail)

Name:_______________________________  Instrument(s):_________________________________

Age:_____  Date of Birth:___________  Sex:____  Social Security Number:_______________________

Permanent address:___________________________________________________________________

City: ______________________________   State:  ______   Zip:  ____________________

Phone:  _________________  Fax:  ________________  e-mail :  _____________________

Temporary (school) address (through June 15, 2001):

__________________________________________________________________________________

City: ______________________________   State:  ______   Zip:  ____________________

Phone:  __________________  Work Phone:  ______________  Mobile Phone:  ___________________

E-mail at school:  _________________________

School you now attend:  _________________________________  Grade/Year:  ___________

Present Teacher’s name:   ____________________________  Phone:   ___________________

Teacher’s address:  ____________________________________________________________________

City: ______________________________   State:  ______   Zip:  ____________________

Name of Wintergreen faculty mentor (if known):  ______________________________________________

(It is not necessary to have a Faculty Mentor to apply.)

Do you wish to be considered for an Academy fellowship:  (Y/N)____________

Attach additional pages, if necessary.

Current and previous musical training:

 

 

Chamber music experience:

 

 

Orchestral experience:

 

 

Content of application tape:

 

 

Applicant Signature:  ________________________________     Date:  ______________________

If under age 18, this completed application must be sent via U.S. Mail and must contain signature of parent / legal guardian.

Parent/legal guardian’s name (please print):   ________________________________________________

Parent/legal guardian’s signature: _________________________________  Date:______________

Academy Housing Information 2001

Name:  _____________________________________   Instrument(s): __________________________

Address (June 1 thru June 27):  _________________________________________________________

City:  ___________________________________   State:________   Zip:  __________________

Home phone: _______________________  Work phone: _____________________________________

Fax:_______________________________   e-mail:  ________________________________________

Hometown newspaper:  ______________________________  Phone:  _________________________

Address:  __________________________________________________________________________

City:  ___________________________________   State:________   Zip:  __________________

Date of arrival: By plane:  ____________________________  By car:  ___________________

  (Charlottesville, VA, is the closest airport. You will need to supply your flight information if you wish to be picked up.)

Date of departure from Wintergreen:  ____________________   

Will you have an automobile?  (Y/N)____________

Your T-shirt size (s, m, l, xl):  _____________ 

Emergency medical insurance:   Company:  _________________________________________________ 

Policy #:  __________________________________

Person to contact in case of emergency:  ________________________________________________

Relationship to applicant: _______________________________________________________________

Persons Emergency Home:  ____________________ Work:_______________  Cell:________________

If applicant is under age 18, this completed application must be sent via U.S. Mail and must contain signature of parent / legal guardian.

In case of emergency, The Wintergreen Summer Music Festival and/or its agents has permission to approve emergency medical care.

Parent/legal guardian’s name (please print):   _________________________________________________

Parent/legal guardian’s signature: _________________________________  Date:______________

Would you like to stay with the same host-family as last year, providing that home is available?  (Y/N)_______

Indicate by which means (above) you wish to be contacted and notified of your housing assignment:

Phone: ________________   Fax:  ______________   e-mail:  __________________________

List any allergies: _______________________________________________________________________

Do you object to pets? (Y/N)____________  

Do you object to smoking? (Y/N)______________

Do you smoke? (Y/N)____________

Do you have any medical conditions which might require special attention? (Y/N)____________

If Yes, explain _________________________________________________________________________

List any special dietary requirements: (Y/N)____________

If Yes, explain _________________________________________________________________________

If the religion of your host-family is important, please indicate your preference: __________________________

List any other needs or concerns:  ___________________________________________________________


To Snail Mail this Academy Application Form
simply print the page and mail to:

Mr. Les Nicholas, Director
Wintergreen Summer Music Academy
1035 South Dogwood Dr.
Harrisonburg, VA 22801

Please Make Checks Payable to:
Wintergreen Performing Arts, Inc