TUCSON JUNIOR STRINGS APPLICATION

P.O. Box 32425

Eastside TJS

Tucson, AZ 85751

Orchestra Placement _____________

( 520) 745-5830

Northwest TJS

FALL 2009

STUDENT INFORMATION
Name___________________________________________Birthdate______________Home Telephone__________________
Address_______________________________________________City________________________State_____ZIP________
Student E-Mail ___________________________________________________ Student Cell __________________________
School_________________________________________________Grade________Orch Director_______________________
Instrument_______________________ Private Teacher_________________________________________________________

PLEASE FILL OUT ENTIRE FORM TO UPDATE OUR RECORDS

PARENT/GUARDIAN INFORMATION
Father______________________________________________________________Cell phone__________________________
Occupation_________________________ Employer_________________________Work phone________________________
E-Mail address________________________________________________________Fax number________________________
Mother______________________________________________________________Cell phone_________________________
Occupation _________________________Employer_________________________Workphone_________________________
E-Mail address________________________________________________________Fax number________________________
EMERGENCY INFORMATION
Primary Doctor __________________________________________________________Telephone______________________
Insurance Company___________________________________________Policy Number_______________________________
Name and relationship of person (other than parent) who could be called in the event of an extreme emergency when we
CANNOT locate parent(s):
Name__________________________________________Relationship_________________Telephone___________________
Any other information you feel we should have on hand should your child become ill or injured:

Insurance Liability Information

The basic coverage of Tucson Junior Strings is as follows:
1. $1,000,000 bodily injury liability
2. $2,000,000 aggregate
3. Medical costs are covered at 100% if the accident is a result of a
TJS function and there is no other insurance in force.
Coverage while in private or public transportation is not included, nor is
coverage for damaged, lost or stolen property (instruments) inclusive.
Please review your own insurance policies for any other coverage you feel you require.
I HAVE READ THE ABOVE STATEMENT REGARDING THE LIABILITY OF TUCSON JUNIOR STRINGS AND FULLY
ACKNOWLEDGE AND ACCEPT THE TERMS AS SET FORTH.

Signature of Parent/Guardian__________________________________________ Date______________

Please fill out reverse side and return this form with payment