| Instrument: |
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| Private Teacher: |
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| Are you applying for the $100 music camp Scholarship?: |
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| Are you applying for the McHose Scholarship?: |
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| Are you applying for the Humphreville Scholarship?: |
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| First Name: |
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| Last Name: |
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| Home Phone Number: |
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| Cell Phone Number: |
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| Parent Email Address: |
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| Student Email Address Optional: |
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| Street Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Age: |
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| School: |
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| Grade: |
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| Years of membership in Youth Symphony: |
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| Years of membership in Junior Orchestra: |
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| Years of membership in Wind Ensemble: |
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| Have you attended a Music Camp?: |
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| Where? |
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| Why do you want to go to music camp?: |
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| What are your future plans in music?: |
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