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Student Information:

Student First Name*:
Student Last Name*:
Student eMail*:
Parent/Guardian 1 First Name*:
Parent/Guardian 1 Last Name*:
Parent/Guardian 2 First Name:
Parent/Guardian 2 Last Name:
Parent/Guardian eMail*:
Address*:
Address2:
City*:
State*: Zip*:
Country*:
Home Phone*:
Work Phone:
Cell Phone:
Student Age*:
Date of Birth*:
Student Race/Ethnicity:*:
Emergency Contact Name:*: Phone*:
eMail:*: Relationship*:
Litchfield Jazz Camp does not discriminate on the bases of race,
creed, color, national origin, or sex.
School*: Grade:
School Music Teacher
First Name*:
School Music Teacher
Last Name*:
Phone: eMail:
Address:
City:
State: Zip:
Private Music Teacher
First Name:
Private Music Teacher
Last Name:
Phone: eMail:
Address:
City:
State: Zip:
Primary Instrument*: Years Played*:
Other Instruments Played:
Jazz Skill Level*:     T Shirt Size*:
Shirt sizes are suggested, we do our best to accomodate everyone.
I Attended LJC In: 2009 2008 2007 2006
2005 2004 2003 2002
2001 2000 1999 1998
How did you hear of LJC?*:
Roommate Request (optional):


Click here to see session pricing.

Session Attendance:

*

Student will be attending*:
Session 1 Session 2 Session 3 Session 4
 (7/11-7/16)  (7/18-7/23)  (7/25-7/30)  (8/01-8/06)


Extra Boarding for Saturday August 7th, 2010 ($60)
(Only available to session 4 residential students staying for the festival)

Private Lessons (Optional) @ $60 per 1/2 hour
(Maximum of 2 per week)
Sess 1 Sess 2 Sess 3 Sess 4

Private Teacher Request:
(Requests will be accomodated where possible, but cannot be guaranteed.)

LJF Nalgene Water Bottle ($12 each)  

Extra Camp Tshirts    
($15 each - 1 Tshirt is already included with registration)

Tuition (but not $200 deposit) is refundable for emergency withdrawals until June 1st. All payments are forfeit for withdrawal only after June 1st. Payments after June 1st are subject to $50 late charge.

Full payment and all required forms are due on or before June 1st

Need-based scholarship support may be available for students age 18 and under

TO APPLY FOR SCHOLARSHIP SUPPORT:
Submit completed application as well as information below. Mail required tax documentation to:
Litchfield Performing Arts
P.O. Box 69
Litchfield, CT 06759

or fax to 860-361-6288

SCHOLARSHIP APPLICATION DEADLINE:
APRIL 17, 2010.
Partial or full scholarship support may be available. All information is confidential.

I would like to apply for scholarship

I receive free/reduced school lunch

Total Household Income:

Number of children in my family:

REQUIRED: 2009 Tax form 1040 pages 1 & 2, plus non-refundable $100 deposit

Notification: On or About June 8, 2010

If you are unable to pay the $100 deposit please call the LPA office.
Please upload your one-page essay (approximately 300 words) about your playing/listening experience (jazz, classical, pop) and what you hope to learn and contribute to Litchfield Jazz Camp. If you are a returning student please tell us how Litchfield Jazz Camp has impacted your life (musically, personally), and why you have decided to return.
ALL files uploaded must be 1.5 megabytes or smaller.
Accepted file types: .jpg, .gif, .bmp, .png, .pdf, .doc, .docx, .rtf, .txt
Upload your Essay*:
Upload your Picture:
Upload your Health Exam Form:
Upload your Check Out Form:
Upload your Camp Permission Form:
Upload your Authorization for Administering Medicine Form:
Upload your Medical Administration Record (MAR) Form:
Upload your Non-Prescription Authorization Form:
Upload your Health Form:

I would like to donate to make it possible for students in financial need to attend.

Review all of the information above to ensure it is correct; once submitted it cannot be changed.
Please click the submit button only once. Submission may take several minutes.
Do not use the back button on your browser during or after submission.

PLEASE NOTE: We are no longer accepting applications for these instruments:
All Instruments except Bass and Voice - Session 4
Drums - Sessions 3 and 4 (Sessions 1 and 2 are still available)
Guitar - Session 2 and 4 (Sessions 1, and 3 are still available)
Saxophone - Session 4 (Sessions 1, 2, and 3 are still available)
Piano - Sessions 2 and 4 (Sessions 1, and 3 are still available)

Your information is kept confidential and used only for the purposes of
receiving information on the Litchfield Jazz Camp and Litchfield Jazz Festival.

Litchfield Performing Arts | P.O. Box 69, Litchfield, CT 06759 | Phone 860-361-6285 | Fax (860) 361-6288 | Contact Us