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New dixie band camp general information

Composer-conductor, Mark Camphouse has served as a guest conductor, lecturer and clinician in 42 states, Canada and Europe. He was elected to membership in the American Bandmasters Association in 1999 and has served as coordinator of the National Band Association Young Composer Mentor Project since 2000. He began composing at an early age, with the Colorado Philharmonic premiering his First Symphony when
he was 17. His 25 published works for wind band have received widespread critical acclaim and are
performed widely in the U.S. and abroad. He holds undergraduate and graduate degrees in Music from
Northwestern University and is Professor and Associate Director of the School of Music at George Mason
University, where he conducts the wind symphony and teaches courses in conducting and composition.
Dixie Band Camp is happy to have Mr. Camphouse as guest clinician for the Sr. Camp Blue Band this summer. THIS YEAR, ANY WOODWIND, BRASS, OR PERCUSSION PLAYER WHO WAS A MEMBER OF EITHER ALL-STATE CONCERT BAND OR JAZZ BAND WILL RECEIVE A SCHOLARSHIP TO “DIXIE” ($250 ON CAMPUS - $125 OFF CAMPUS). PLEASE SEND THE $50.00 BALANCE WHEN YOU SUBMIT YOUR APPLICATION! All ON-CAMPUS fees provide for tuition, room, meals, recreations, CAMP ANNUAL. All OFF-CAMPUS fees provide for tuition, recreation, NOON MEAL, CAMP ANNUAL. Note: All applications postmarked by June 1, 2012 will receive a FREE T-SHIRT.
All applications postmarked after June 1, 2012 will be assessed a $25.00 LATE FEE.
ELIGIBILTY: JUNIOR CAMP—Students having completed grades five, six, seven, or eight and has completed six
months of instrumental training. SENIOR CAMP—Any student having completed grades nine, ten, eleven, or twelve
and who has completed one year of instrumental training.
ENROLLMENT: Enrollment will be limited to 800 students ON CAMPUS per week.
There is no limit to OFF CAMPUS enrollment. RECREATION: Sports and social activities including dancing, swimming, karaoke (Jr. Camp only) and other
entertaining features will be under the supervision of qualified directors.
FACULTY: Outstanding junior high, high school and college personnel.
HOUSING: Students are housed very close to all activities in air conditioned dormitories. The camp will not be
responsible for the loss of personal items.
REGISTRATION: SENIOR CAMP SUNDAY, JUNE 10th, 9:30 a.m. until 12:30 p.m.
JUNIOR CAMP, SUNDAY, JUNE 17th, 8:00 a.m. until 12:30 p.m. Registration for both camps will be held in the SNOW FINE ARTS BUILDING on the campus of The University of Central Arkansas in Conway, Arkansas. Additional information is available from: Dixie Band Camp
P.O. BOX 10058
JONESBORO, AR 72403
NAME __________________________________________ PARENT___________________________________________ MAILING ADDRESS__________________________________________________________________________________ CITY____________________________________________ STATE_______________________ ZIP _________________ AGE________________________ SEX_______________________ PHONE ( )________________________________ NAME OF SCHOOL____________________________________________ GRADE COMPLETED MAY 2012_________ BAND DIRECTOR___________________________________________ PREVIOUS YRS. AT DIXIE________________ YEARS STUDIED___________________ YOUR INSTRUMENT (Be specific) ____________________________________ T-shirt size (Circle one) S M L XL XXL (Adult Sizes Only) Application deadline to receive a FREE T-SHIRT is June 1, 2012 (If no size indicated, you will receive Large) A minimum deposit of $175.00 must accompany this form. Make your check or money order payable to DIXIE BAND CAMP. Optional $15.00 (Wild River) Fee Enclosed $___________________________ Late Fee Enclosed $___________________________ TOTAL AMOUNT ENCLOSED $___________________________ REQUIRED MEDICAL HISTORY & CONSENT FOR TREATMENT FOR CAMPS AT THE UNIVERSITY OF CENTRAL ARKANSAS Camp child will be attending__________________________________ Dates __________________________________ Camper’s Name_________________________________ Age______________ DOB____________________________ Street Address__________________________________ City_____________________ State_______ Zip____________ Parent/Guardian______________________________ Address____________________ State ______ Zip ____________ Telephone ___________________________________ Cell Phone ___________________________________________ EMERGENCY CONTACT- In case of Emergency, if parent cannot be reached, name of person to notify or to who we can release camper to in your absence. NAME__________________________________ Telephone ________________________ CIRCLE ALL CONDITIONS CAMPER CURRENTLY HAS OR HAD IN PAST Constipation Bed Wetting Sleepwalking Ear Problems Asthma Seizures Diabetes Bronchitis Frequent colds Sinusitis Nausea Vomitting Eating disorder Heart problems Cancer Kidney problems Homesickness Abdominal problems Menstrual problems Sore throat Other medical conditions:_______________________________ ALLERGIES: Drug _____________________ Bee Stings ______________________ Latex_________________________ NAME OF CAMPER’S PHYSICIAN__________________________________ PHONE ___________________________ INSURANCE COMPANY__________________________________________ MEMBER #__________________________ IMMUNIZATIONS: Last Tetanus Injection _________________________ PRINT PARENT/GUARDIAN NAME_______________________________________________________________________ PARENT/GUARDIAN SIGNATURE___________________________________________ DATE ______________________ If medication consent form is not completed, medication will not be administered to the camper. CURRENT MEDICATIONS WITH DOSAGE SCHEDULE:_____________________________________________________ _______________________________________________________________________________________________________ MEDICATIONS CAMPER TAKES AS NEEDED, i.e. Tylenol, Ibuprofen, Midol, Tums, Benedryl, Claritin, Cough medication, Skin Creams:_________________________________________________________________________________________________ REQUIRED PARENT/GUARDIAN CONSENT
I understand that I am giving consent for my child to receive treatment for minor illness and injuries as directed by the Advanced Practice Nurses in the
Health Clinic. This medical history/medication consent form is correct as far as I know and I understand that both forms must be filled out COMPLETELY
in order for my child to receive treatment at a UCA Camp. I understand that in case of an emergency, every effort will be made to contact a parent or
guardian prior to treatment. However, if the parent or guardian cannot be reached and the situation requires immediate emergency attention as determined by
the camp staff or by the clinic staff, I hereby authorize representatives of the camp to obtain emergency treatment for my child as deemed necessary. I
AGREE TO THE RELEASE OF ANY RECORDS NECESSARY FOR TREATMENT OR REFERRAL OF THE MINOR CHILD.
MEDICATIONS, PRESCRIPTIONS: Arkansas State Law requires parental authorization to administer any prescription medications brought by campers.
Prescribed medications MUST be in original container with the pharmacy label showing number, patient name, date filled, physician name, name of medica-
tion and directions for use.
I authorize __________________________, my child; to take his/her own medication or the camp health care supervisor to administer to my child any prescribed medication being brought to camp. NON-PRESCRIPTION MEDICINES: I authorize my child to take his/her own over-the-counter medications □Yes □ No
I authorize the health care designee to administer the non-prescription medications as deemed necessary for the camper’s comfort, as listed above.
□Yes □ No PARENTS SIGNATURE____________________________________________________________________________________
AGREEMENT FOR ASSUMPTION FOR RISK & RELEASE INDIVIDUAL PARTICIPANT RELEASE
I, _____________________________, THE UNDERSIGNED, BEING ALLOWED TO USE THE FACILITIES OF THE University of Central Arkansas (hereinafter “University”) for activities related to Dixie Band Camp (hereinafter “the event”), on June 2012, do hereby release and forever discharge the Uni-versity and Dixie Band Camp Inc., and all their officers, agents, employees, trustees, and/or successors in interest from and against any and all claims of dam-ages, demands, and actions, or causes of action, on account of damage to personal property, personal injury, or death which may result from my participation. Specifically, I release the University and Dixie Band Camp Inc., and all of their officers, agents, employees, trustees, and/or successors in interest, from any claims against them, which relates to my participation in activities related to the event while on the campus of the University or traveling to or from the event. I acknowledge for myself that I am the recipient of a privilege from the University and Dixie Band Camp. I understand that privilege is a tangible benefit to me. I also fully understand that my participation in activities related to the event at the University is voluntary and that I am not required to participate. I hereby attest and verify for myself that I have full knowledge of the risks involved in participation in the event at the University and assume those risks and will assume and pay my own medical expenses and emergency expenses in the event of an accident, illness, or other incapacity. I attest that I am physically fit and sufficiently trained to participate in the event at the University. Should injury or illness occur while on campus, I give my permission to receive treat-ment, if necessary, from UCA Student Health Services and/or a local Conway health-care provider at my expense. I, for myself, accept full responsibility for any use of all facilities, including property of the University; and agree to make full restitution with regard to any compensation required as a result of my participation or use, misuses, damage, or negligence to such properties. It is my express intent that this Agreement for Assumption of Risk and Release shall bind my family and spouse, if I am alive, and my heirs, assigns or personal representatives, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO INSTITUTE LEGAL ACTION AGAINST THE ABOVE-NAMED RELEASEES. I HEREBY FURTHER AGREE THAT THIS RELEASE SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF ARKANSAS. I further hereby agree to indemnity and hold harmless the releasees from any loss, liability, damage or costs, including court costs and attorney’s fees, that they may incur due to my participation in said activity. In signing this Agreement for Assumption of Risk and Release, I acknowl-edge and represent that I have read the foregoing and freely and voluntarily agree to its terms. I further acknowledge that no oral representations, statements, or inducements, apart from the foregoing written Agreement, have been made, and that I am at least eighteen (18) years of age and fully competent. In wit-ness whereof, I have cause this Agreement For Assumption of Risk and Release to be executed This ____________________ day of _____________ 2012. Student Signature __________________________________________ *IF THE UNDERSIGNED IS A MINOR (UNDER 18 YEARS OF AGE), A PARENT OR LEGAL GUARDIAN MUST SIGN THE DOCUMENT
BELOW.

AGREEMENT FOR ASSUMPTION OF RISK & RELEASE OF PARENT OR LEGAL GUARDIAN FOR A MINOR
I, ___________________________________________, Parent or Legal Guardian of,_______________________________ acknowledge and represent that I have read the foregoing Agreement for Assumption of Risk and Release, and that I understand and sign it on behalf of my minor son/daughter or foster child, voluntarily as my own free act and deed. I further acknowledge that no oral representation, statement or inducements, apart from the foregoing written Agree-ment, have been made. It is my express intent that this Agreement for Assumption of Risk and Release shall bind the members of my family and spouse, if I am alive, and my heirs, assigns or personal representatives, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVE-NANT NOT TO INSTITUTE LEGAL ACTION AGAINST RELEASEES NAMED IN THE AGREEMENT FOR ASSUMPTION OF RISK AND RE-LEASE ATTACHED HERETO. I HEREBY FURTHER AGREE THAT THIS RELEASE SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF ARKANSAS. In witness whereof, I have caused this Release of Parent or Legal Guardian for Minor to be executed this ___________________________ day of ___________ 2012. Parent or Legal Guardian_______________________________________________________ WILD RIVER COUNTRY INFORMATION & PERMISSION FORM
WILD RIVER COUNTRY has been tentatively scheduled again this year as an OPTIONAL night activity for the 2012 SENIOR & JUNIOR SESSIONS of
camp. WILD RIVER COUNTRY is a water theme park located in North Little Rock. If you would like for your child to participate in this activity, the per-
mission form below MUST be filled out and returned along with the $15.00 admission fee. We will not be able to accept Wild River Country applications
after 1:00pm on the first day of camp. A parent/guardian MUST sign the form. Students will be transported to and from WILD RIVER COUNTRY on school
buses driven by licensed drivers. Participation in this activity is optional and alternate recreational activities will be provided for those who choose not to
participate.
I GIVE PERMISSION FOR MY CHILD, ___________________________________ TO PARTICIPATE IN THE WILD RIVER COUNTRY Parent/guardian Signature_______________________________________________ Date______________________ Amt Paid _____________

Source: http://www.dixiebandcamp.net/uploads/2012_DBC_Application.pdf

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