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CHIME Program

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CHIME Registration

Musician Information

Which CHIME location are you registering for?

CHIME Status

If returning, what year did you begin CHIME?

When were you last in CHIME?

First Name

Last Name

Date of Birth

Current Age

Gender

Which category best describes student's ethnicity? Check all that apply.

Prefer Not To Disclose

American Indian

Asian

Black/African American

Caucasian

Hispanic/Latino

Other

Mixed

Submission of this information is optional. This information will be used for reporting purposes. Thank you for your voluntary participation.

Musician Contact Information

Preferred Phone

Street Address

Street Address 2

City

State

Zip Code

County of Residence

School Information

Grade

School Name or Homeschool

School Music Teacher's First Name

School Music Teacher's Last Name

School Music Teacher's Email

School Music Teacher's Phone

School District

School Phone

Parent /Guardian 1

First Name

Last Name

Relationship to the musician

Email

Preferred Phone

Do you wish to receive text notifications?

Address same as musician's?

Street Address

Street Address 2

City

State

Zip Code

Employer

Position

Parent /Guardian 2

First Name

Last Name

Relationship to the musician

Email

Preferred Phone

Do you wish to receive text notifications?

Address same as musician's?

Street Address

Street Address 2

City

State

Zip Code

Employer

Position

Emergency Contact

Emergency Contact Name

Relationship to Musician

Emergency Phone Number

Additional Information

T-Shirt Size

Do you need assistance providing your child with concert dress?

Promotional Photos/Video - Parental Permission

Please check whether you DO or DO NOT give permission for your child's photo and/or performance video to be used for promotional and public relations purposes. Please note: ESYO cannot be held responsible nor liable for the publication of material created that may contain images of ESYO musicians and/or posted by anyone without ESYO's knowledge or authorization.

Dietary Restrictions

We provide afterschool snacks for all CHIME participants. The snacks are predetermined, but to aid in supporting your child during snack time, please let us know of their restrictions.

No Allergies

No food restrictions

Allergies

Gluten-free

Kosher

Halal

Lactose Intolerant

No shellfish

No red meat

Vegetarian

Vegan

Other

Special Diet - Allergy Specification

Special Diet - Other Specification

Transportation

Please indicate which days each week will your child be attending CHIME?

Monday

Tuesday

Wednesday

Thursday

Friday

Are you able to pick up your child after the program?

Carpool Directory

Please check whether you would like your name to be on a list to be shared for carpooling purposes.

Yes, I would like to be added to the carpool list.

No, Please do not share my information.

Do you anticipate needing bus transportation?

Musician's Personal Committment

I accept membership in the ESYO CHIME program. By accepting this offer I certify that I have read the attendance and behavior rules and policies for CHIME members published on ESYO's website and I agree to abide by the policies and rules outlined therein.

Parent/Guardian's Certification

I certify that I am the parent/guardian of the musician referenced in this registration form and that he/she accepts membership in the CHIME program offered to him/her by ESYO. My child and I have read attendance rules, behavior rules and policies for members published on ESYO's website and we agree to abide by the policies and rules outlined there.

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Empire State Youth Orchestra at Proctors
432 State Street, Schenectady, NY 12305
Phone: 518-382-7581 | Fax: 518-382-0254

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