Keith Country Day School presents Rock Camp

Register by Mail/Fax
To register for Rock Camp by mail/fax, download and complete the
Rock Camp 2012 Application and get it to us.

Rock Camp 2012
c/o Keith Country Day School
1 Jacoby Place,
Rockford, IL 61107

Fax
815.399.2470

Name

First Name
Last Name

Other Info

Age
Email
Birthday
GenderMaleFemale

Address

Street
Apartment Number
City
State
Zip

Emergency Information

Parent/Guardian Name
Home Phone
Work Phone
Cell Phone
Emergency Contact Name
Emergency Contact Number

What do you play?

Instrument Other
Taking Lessons ? For How Long?
Self Taught ? For How Long?
On a scale from 1 - 10, What is your Skill Level?

List 3-6 tunes you would like to learn at the camp.
(Songs to learn for the camp concert will be
selected by the staff based on student
suggestions.)

Song Title - Artist
Song Title - Artist
Song Title - Artist
Song Title - Artist
Song Title - Artist
Song Title - Artist

Bandmate Requests (Student's Name)
How did you hear about us
If reffered, by whom?

Additional information that would help ensure proper placement.

Pay Now or Later?
Now (Credit Card) Later (Check or Cash)

By selecting "Now", after submitting this form, you will need to click on the link to pay by Paypal.
If paying "Later", Payment is due before April 15th to be applicable for early registration.

Registering for which week(s)

Week 1 ( June 13 - 17 ) $325.00
Week 2 (June 20 - 24) $325.00