Complete And Sign all these enclosed forms - Jam Camp WEST
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Please
Complete And Sign
all these enclosed forms
and return to us via mail to:
Living Jazz
1728 San Pablo Ave.
Oakland, California 94612
You may also complete, sign, scan and email all forms to:
denise@livingjazz.org
If you have any questions
please contact us via email at:
denise@livingjazz.org
or by phone at
510-858-5313Jam Camp West Forms Checklist
All other packet contents not listed here are for your records. Please return these items listed
below to Living Jazz before June 30, 2018
❑ Rules and Regulations Signature Page-
Consent and Release Form
❑ Health History Form
❑ Class Selection Sheet
❑ T-Shirt Order Form
❑ Payment of Tuition Balance
(if not already submitted)
❑ Media Release
NOTE: If you need a reminder of your balance, please feel free to call or email.
510-858-5313 ~ denise@livingjazz.org
Please print out all pages, sign where needed, and send the above materials
to:
LIVING JAZZ
1728 San Pablo Ave.
Oakland, CA, 94612
Or scan and email back to: denise@livingjazz.orgJam Camp West Rules and Regulations Signature Page
All signed forms must be received by Living Jazz PRIOR TO THE START DATE OF JAM CAMP
Camper Name_________________________________________________________________________
We have read the Rules and Regulations, we understand those rules and regulations, and we agree to adhere to and abide
by those rules and regulations.
__________________ _________________________________________________________________________
(Date) (Camper’s Signature)
___________________________________________________________________________________________
(Parent/Guardian’s Signature) (Print Name of Parent/Guardian)
PARENT/GUARDIAN CONSENT AND RELEASE
I hereby give my permission to the physician selected by Jam Camp West to order x-rays, routine tests, and whatever other
treatment the physician determines is reasonably prudent for the health of my child,
____________________________________________ (camper’s name). In the event that I cannot be reached in an
emergency, I hereby give my permission to the physician selected by Jam Camp West to hospitalize, secure proper
treatment for, and to order injection, anesthesia, and/or surgery for the above named camper.
I agree to pick up camper immediately if called upon to do so by Living Jazz Executive Director, Stacey Hoffman.
I understand that camper may be dismissed from camp if he or she fails to abide by Jam Camp West’s Rules and
Regulations or fails to participate adequately in Jam Camp West activities.
I recognize that the camper must follow safety instructions, remain in areas designated by Jam Camp West staff and
volunteers, and refrain from behavior that is harmful to him/herself or to others. Recognizing that Jam Camp West will do its
best to ensure a safe experience, I understand that certain dangers or accidents may occur. I hereby release Living Jazz,
Inc., Jam Camp West as well as its directors, officers, staff, and volunteers from any and all responsibility and liability of any
nature, including claims of injury, illness, death, loss, or damage resulting from the camper’s participation in Jam Camp
West.
I hereby acknowledge and agree that I shall be solely responsible, along with camper, for any damage that camper may
cause to other persons or to property, regardless of the nature of the damage or claims, and to indemnify and hold Living
Jazz harmless from any costs, damage or injury to any person or property arising from or related to camper’s participation in
Jam Camp West.
_______________________________________________________________________________________________
(Date) (Camper’s Name)
_______________________________________________________________________________________________
(Parent/Guardian’s Signature) (Print Name of Parent/Guardian)
Mail: Living Jazz, 1728 San Pablo Ave., Oakland, CA 94612; Sign, and email back to : denise@livingjazz.org
Please fill out completely, SIGN and RETURN these forms to: Living Jazz, 1728 San Pablo Ave., Oakland, California, 94612Media Release
Camper Name_________________________________________________________
During the week of Jam Camp West, there will be professional photographer and
videographer at camp. By signing below, you are authorizing that any media taken of your
child during Jam Camp West may be used by Living Jazz for promotional purposes.
I hereby release any and all rights I may have to any photos taken of my child during
Jam Camp West for Living Jazz promotional purposes.
___________________
Date
___________________________________ ____________________________________
Parent/Legal Guardian – Signature here Parent/Legal Guardian – Print name hereJam Camp West Health History Form: (To be completed by Parent/Guardian)
The information on this form is not part of the camper acceptance process and is gathered to assist us in identifying
appropriate care.
Camper Name________________________________________________Birth Date ___/___/___ Age ___ Gender ___
Last First
Grade entering Fall 2018____________________ School________________________________________________
Address__________________________________________________________________________________________
# and Street Apt. # City State Zip
Parent/Guardian 1____________________________________ Primary Phone _________________________________
Name Area Code First
Address__________________________________________________________________________________________
(if different from above) # and Street Apt. # City State Zip
Other Phone: (cell)_____________________________ (wk)_______________________________________________
Area Code First Area Code First
Parent/Guardian 2____________________________________________ Primary Phone ________________________
Name Area Code First
Address__________________________________________________________________________________________
(if different from above) # and Street Apt. # City State Zip
Other Phone: (wk)_______________________________ (cell)_______________________________________________
Area Code First Area Code First
Emergency Contact___________________________Phone_______________ / ________________________________
Name Home Alternate
Insurance Information
Is camper covered by family medical or hospital insurance? ___Yes ___No
MediCal/Healthy Families? ___
Carrier Name_____________________ Group #________________ Policy/MR #________________
Carrier Address_______________________________________ Phone _______________________
Family Doctor ______________________________________ Phone _________________________
Dentist ______________________________________ Phone _____________________________Section 1: Allergies Camper Name ______________________________________________ _____Initial here if camper has NO KNOWN ALLERGIES. (Skip to Section 2) Please list ALL known allergies. Please describe reaction and management of reaction. a) Medication Allergies: _____________________________________________________________ ________________________________________________________________________________ b) Food Allergies: _________________________________________________________________ ________________________________________________________________________________ c) Other Allergies (Include insect bites, hay fever, asthma, animal dander, etc.): ________________ ________________________________________________________________________________ Section 2: Medications _____Initial here if camper takes NO PRESCRIPTION MEDICATIONS ON A ROUTINE BASIS. Please list here ALL medications routinely taken. Bring/send enough medication for the camper’s entire stay at Jam Camp WEST. Be sure to send any medications to camp in the ORIGINAL PHARMACY PACKAGING/BOTTLE that identifies (1) prescribing physician (if prescription drug), (2) name of medication, (3) dosage and frequency of administration. Please also send any equipment necessary for medication administration including spacers for inhalers, peak flow meters, etc. Med. #1 ____________________________ Dosage _____________ Specific Time to be Taken Daily ______________ AM / PM Purpose for Medication______________________________________________________________ Med. #2 ____________________________ Dosage _____________ Specific Time to be Taken Daily ______________ AM / PM Purpose for Medication _____________________________________________________________ Med. #3 ____________________________ Dosage _____________ Specific Time to be Taken Daily ______________ AM / PM Purpose for Medication _____________________________________________________________ Please attach additional pages for more medications if necessary. You may list here any non-prescription medications/vitamins to be taken by or administered to camper while at Jam Camp West: __________________________________________________ ________________________________________________________________________________
**IMPORTANT: For campers’ safety, please do not send common medications such as aspirin, ibuprofen, etc. to camp. Our infirmary will stock common over-the-counter medications for dispensation by the camp nurse. Please fill out completely, SIGN and RETURN these forms to: Living Jazz, 1728 San Pablo Avenue, Oakland, California, 94612 Section 3: Dietary Restrictions _____Initial here if camper has NO DIETARY RESTRICTIONS. Check all that apply. Camper DOES NOT EAT: __ red meat __ dairy __ poultry __ nuts __ fish __ berries __ shellfish/seafood Other (please specify): __ pork ______________________________________ __ eggs Section 4: Health History – General Questions Does/Has camper: Y / N H Y / N Have an orthodontic appliance to be Y / N Ever had seizures? brought to camp? Y / N Had any recent injury, illness, or infections Y / N Have any skin problems disease? (ie: itching, rash, acne, etc.) Y / N Have a chronic or recurring illness or Y / N Have diabetes? condition? Y / N Have asthma? Y / N Ever been hospitalized? Y / N Have problems with sleep-walking? Y / N Ever had surgery? Y / N Have a history of bed-wetting? Y / N Have frequent headaches? Y / N Had mononucleosis in the past 12 months? Y / N Ever had a head injury? Y / N Had problems with diarrhea/constipation? Y / N Ever been rendered unconscious? Y / N Commenced her menstrual period? Y / N Wear glasses, contact, or protective Y / N Ever had an eating disorder? eyewear? Y / N Ever had emotional difficulties for which Y / N Ever had frequent ear infections? professional help was sought? Y / N Ever lost consciousness during or after Had any of the following diseases? exercise? Y / N Measles Y / N Ever been dizzy during or after exercise? Y / N Mumps Y / N Ever had chest pain during or after Y / N Chicken Pox exercise? Y / N German Measles Y / N Ever had high blood pressure? Y / N Hepatitis A Y / N Ever been diagnosed with a heart Y / N Hepatitis B murmur? Y / N Hepatitis C Y / N Ever had back problems? Y / N Any other conditions not mentioned Y / N Ever had joint problems? (ie: knees, here? ankles, etc.)
(continued on Page 4) If you answered “Yes” to any of the previous questions, please explain and date Please describe any additional information about your camper’s emotional, behavioral, physical, or mental health that may be of significance in attending the Jam Camp West program. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ______________________________________ (Date) __________________________________________________________________________ (Print Camper’s Name) _________________________________________________________________________ (Parent/Guardian Signature) _________________________________________________________________________ (Print Name of Parent/Guardian)
Jam Camp West 2018 Class Selection Sheet
*Make sure to review ALL Class Descriptions with your camper before filling out this form. This must be returned in ADVANCE of camp.
st nd st
Campers MUST choose a 1 and 2 choice for each class slot. Please put ONLY 1 check in column 1 for 1 choice and 1 check
in column 2 for 2nd choice. We will do our absolute best to accommodate all campers’ choices and areas of major interest. Campers
will stay with the schedule they create for the duration of camp. Remember: When choosing an ensemble, YOU MUST put the instrument
your camper will play for that specific ensemble.
Camper’s Name: _________________________________________________________________________________
st nd
1 ch. 2 ch.
9:00-10:00 ____ ____ World Jazz Dance I – Beg/Mixed Level; Natalie Aceves - Dining Room
____ ____ Rock Ensemble - All Levels; Josiah Woodson - Main Stage
Required: Camper’s Instrument: _______________________________________
____ ____ Adv. Instrumental Combo- Adv.; Terrence Brewer- (by audition on first day of camp)- Jam Room
____ ____ The Grooves of The Blues: Shuffles, Swings, Funks – All Levels; Faye Carol; Shepard Lodge
____ ____ Music, Theory and Nature- All Levels; Kyle Blase- Vocal Circle
____ ____ Big Fun On The Steel Pans - All Levels; Mark Rosenthal - Steeldrum Pogoda
____ ____ The Elements - All Levels; Joshua Woodson- Retreat Lodge
____ ____ Words, Writing and Rap - All Levels; Charles Simon - Minor Stage
10:15-11:15 ____ ____ Hip - Hop Love - Beg./Int.; - Samara Atkins- Dining Room
____ ____ Rock, Pop, Hip-Hop & More Ensemble - Int./Adv.; Daria Johnson, Josiah Woodson- Main Stage
Required: Camper’s Instrument: ________________________________________
____ ____ All Levels Guitar Ensemble - All Levels, Terrence Brewer- Jam Room
____ ____ Writing Your Blues- All Levels; Faye Carol- Shepard Lodge
____ ____ Vocal Ensemble- All Levels; Bryan Dyer- Vocal Circle
____ ____ Intro To Afro-Cuban Music - All Levels; Javier Navarrette- Shepard Fire Ring
____ ____ Big Fun On The Steel Pans - All Levels; Mark Rosenthal- Steeldrum Pogoda
____ ____ Remix, Arrangement, Mashup? - All Levels; Joshua Woodson- Retreat Lodge
2:30-3:30 ____ ____ Performance Hip - Hop - Int./Adv.; Samara Atkins- Dining Room
____ ____ Rhythm And Groove Ensemble - Int./Adv.; Daria Johnson, Terrance Brewer- Main Stage
Required: Camper’s Instrument: _________________________________________
____ ____ Improvisation for all instrumentalists- All Levels- Josiah Woodson- Jam Room
____ ____ Jazz Vocals- All Levels; Bryan Dyer – Shepard Lodge
____ ____ Ukuele Orchestra - All Levels; Kyle Blase – Minor Stage
____ ____ Funky Percussion - All Levels; Javier Navarrette- Shepard Fire Ring
____ ____ Expression Through Songwriting - All Levels; Charles Simon- Vocal Circle
____ ____ From Concept To Studio And Beyond - All Levels; Joshua Woodson- Retreat Lodge
3:45-4:45 ____ ____ World Jazz Dance II- Int./Adv.; Natalie Aceves - Dining Room
____ ____ Blues Ensemble - All Levels; Daria Johnson - Main Stage
Required: Camper’s Instrument: ____________________________________________
____ ____ The Roots of R&B – All Levels; Faye Carol; Shepard Lodge
____ ____ Intro To Afro-Cuban Music - All Levels; Javier Navarrette- Shepard Fire Ring
____ ____ Beatbox 101 - All Levels; Bryan Dyer- Jam Room
____ ____ Big Fun on The Steel Pans - All Levels; Mark Rosenthal- Steeldrum Pogoda
____ ____ Ukuele Orchestra - All Levels; Kyle Blase – Minor StageCamper Name
__________________________________________________________________
Jam Camp West T-Shirt Order Form
Be sure to keep a fun memento of your summer at Jam Camp West!
Please pre-order your Camp T-shirts here. We order numbers of shirts based
on how many campers pre-order them. T-shirts are $15 each. This is a 100%
cotton shirt with the new Jam Camp West design. Check the appropriate box
below for size selection, indicate quantity, and enclose your payment with this
form.
o Adult Small Quantity: _____
o Adult Medium Quantity: _____
o Adult Large Quantity: _____
o Adult XL Quantity: _____
T-shirts will be available for pick-up at registration on the first day of Camp
___ Please find my check payment enclosed for my child’s T-shirt
___ I’d like to pay by Credit Card ___ VISA ___ MC
Card No. __________________________________
Exp. Date ________ Sec. Code ________You can also read
