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CHIME Program

CHIME Team

Application

Registration

Get Involved

CHIME Registration

To register for CHIME in Fall 2020, you must be a previous CHIME student or been accepted into CHIME following a completed CHIME application. New students interested in CHIME must complete the application first here.

2020 CHIME Registration Form

Musician Information

Musician First Name

Musicians Last Name

Date of Birth

Current Age

Gender

Other (Please Specify)

Pronouns

Other (Please Specify)

Ethnicity

Prefer Not To Disclose

American Indian

Asian

Black/African American

Caucasian

Hispanic/Latino

Other

Mixed

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

What school do you attend?

If other, what school?

What instrument do you play?

Where is your CHIME instrument currently located?

If Other, please indicate location:

When were you last in CHIME?

If returning, what year did you begin CHIME?

Musician Contact Information

Musicians preferred phone

Musicians preferred email

Musicians Street Address

Musicians Street Address 2

City

State

Zip Code

County of Residence

School Information

Grade Grade starting September 2020

School Name or Homeschool

School District

School Music Teacher's Email

School Music Teacher's Phone

Parent/Caregiver 1

Parent/Caregiver First Name

Parent/Caregiver Last Name

Relationship to musician

Preferred email

Preferred phone

Do you wish to receive text notifications?

Address same as musician's?

Parent/caregiver Street Address

Parent/caregiver Street Address 2

Parent/caregiver city

Parent/caregiver zip code

Parent/caregiver employer

Parent/caregiver position

Parent/Caregiver 2 Information

Parent/caregiver 2 First Name

Parent/caregiver 2 Last Name

Relationship to the musician

Parent/caregiver 2 Preferred Email

Parent/caregiver 2 Preferred Phone

Do you wish to receive text notifications?

Address same as musician's?

Parent/caregiver 2 Street Address

Parent/caregiver 2 Street Address 2

Parent/Caregiver City

Parent/Caregiver State

Parent/Caregiver Zip Code

Parent/Caregiver 2 Employer

Parent/Caregiver 2 Position

Emergency Contact

Emergency Contact Name

Relationship to Musician

Emergency Phone Number

Additional Information

T-Shirt Size

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.

When CHIME operates in-person, 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

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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