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Spring & Fall 2021
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Cirque de la Symphonie
Registration for 2021-2022 Season
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Student Last Name*
Student First Name*
Double bass/Standup bass
Interested in Jazz
Bass or Bass guitar
Student Email (gmail preferred)
Student Cell Phone (xxx-xxx-xxxx)
Home Phone (xxx-xxx-xxxx)*
Are you enrolled in your school music program?**
School Music Teacher
School Music Teacher Email
Private Music Teacher
Private Music Teacher Email
Parent 1 Name*
Parent 1 Email* (gmail preferred)
Parent 1 Cell Phone (xxx-xxx-xxxx)*
Parent 1 Occupation
Parent 1 Employer
Parent 2 Name
Parent 2 Email (gmail preferred)
Parent 2 Occupation
Parent 2 Employer
Parent 2 Cell Phone (xxx-xxx-xxxx)
EMERGENCY CONTACT 1 Name*
EMERGENCY CONTACT 1 Phone (xxx-xxx-xxxx)*
EMERGENCY CONTACT 2 Name
EMERGENCY CONTACT 2 Phone (xxx-xxx-xxxx)
How did you hear about GCTYO?
Please list any allergies your child has.
Please list any medications your child is taking.
Any other information like medical needs or learning style that GCTYO should know about your child.
New Student Auditions will be held in person in Fairfield on June 9, 2021. We will send instructions after we receive your registration form.
If you do not consent to the Publicity release, uncheck this box
Clicking the Submit button below indicates you have read and understand the information in this box. AUTHORIZATION: My child has permission to engage in all program activities. I am aware of, and accept, any risk inherent in the program activities. I will inform GCTYO of any special health conditions, including required medication and activity limitations, which should be known to GCTYO staff and/or medical personnel in the event of a medical emergency. I understand that participation in GCTYO requires regular attendance at rehearsals and following GCTYO rules as outlined in the membership handbook, including zero-tolerance for bullying and inappropriate behavior. I understand that GCTYO will send email and/or other communications to the email addresses and phone numbers listed on my registration form. REPRESENTATIONS: As is inherent in any musical learning or rehearsing environment, there may be limited, incidental and insignificant physical contact between students and/or teaching staff. At no time will a single student ever purposely be alone in a room with any one GCTYO staff adult, with the exception of private instrumental lessons, which will be a 1:1 ratio with no other adults present. Parents are free to sit in on private lessons by request. PUBLICITY RELEASE: I hereby consent to the use of my child’s likeness (“Likeness”) for the purpose of promotion, publicity, advertising, or other media by GCTYO, or any other representative authorized to act on behalf of GCTYO. Likeness may appear in, but are not limited to, photographs, sound and/or video recordings, films, and broadcasts and may be published in materials such as, but not limited to, brochures, publications, reports, social media (including Facebook, Instagram & Twitter), web pages, promotional materials or any other audio-visual, electronic, printed, tangible work in any media or format, now known or hereafter to become known, and/or reproductions of any of these. I agree that the actual material involved is and shall continue to be the property of GCTYO and that neither I, nor my child, shall have any right of review or approval regarding the use of my child’s Likeness in such material. I hereby release and hold harmless, GCTYO along with their respective employees, agents, affiliates, sponsors, or other representatives from any and all claims, demands, or causes of action arising out of the use of my child’s Likeness, in accordance with the terms of this release. I understand and agree that neither I, nor my child, will be compensated in any way for the use of my child’s Likeness by GCTYO.
** Students must be enrolled in their school music program to participate in GCTYO.