JAZZJuilliard

Summer 2012Camps and Workshops

West Palm Beach Bak Middle School of the Arts1725 Echo Lake Drive, West Palm Beach, FL 33407

In partnership with

June 11-15 for students in Grades 6-8June 18-22 for students in Grades 9-12

One-week programs for students who arededicated, disciplined, and passionate about jazz

For details see Juilliard’s Web site: juilliard.edu/summerjazz or call (212) 799-5000 ext. 7380

Application Deadline: May 2, 2012

For details see Juilliard’s Web site: juilliard.edu/summerjazzor call (212) 799-5000 ext. 7380

West Palm Beach, FL • June 11-15 • June 18-22

The Summer Jazz Residencies in West Palm Beach, FL are one weekprograms for students who are dedicated, disciplined, and passionate

about jazz. Located at Bak Middle School of the Arts, the programs aredesigned to give young jazz musicians a taste of what a Juilliard Jazzstudent’s life is all about; refining technique, performance, and broadeningunderstanding of various jazz styles. Teachers include members of theJuilliard Jazz Studies faculty as well as Juilliard Jazz students.

Instruments for the Juilliard Summer Jazz Residency in West Palm Beach:Trumpet, Saxophone, Trombone, Guitar, Piano, Double Bass,Electric Bass, and Drums.

Please note:

• Guitar, Double Bass, and Electric Bass students are required to bring theirown amp and pick-up cables to all rehearsals and performances.

• There is no vocal program.

JAZZJuilliard

Summer 2012Camps and Workshops

Music Requirements for Juilliard Summer Jazz Residencies in West Palm BeachEach camp will begin with placement into ensembles. Students should be prepared to:• Play C Jam Blues by Duke Ellington• Advanced students may choose a jazz standard from the list below:

– Blue Bossa– Autumn Leaves– Stella by Starlight– Now’s The Time

• Students may be asked to play 1 major and/or1 minor scale (2 octaves)

LocationAll classes and concerts for the Juilliard Summer Jazz Residencies will take place at Bak Middle School of the Arts,1725 Echo Lake Drive, West Palm Beach, FL 33407. Students and parents are expected to make their owntransportation arrangements; no bus service will be provided. Students are expected to bring lunch and snacks daily.Program structure may be adjusted according to enrollment. No housing is provided.

Please contact Ms. Rebekah Gilbert at (212) 799-5000 ext. 7380 if the student has special needs or requires a reasonable accommodation.

Admissions• The Juilliard Summer Jazz Residencies will take place June 11-15 (Grades 6-8) and June 18-22 (Grades 9-12), 2012.• Applicants should complete the attached application; the application deadline is May 2, 2012.• A completed application includes the application form and a $150 non-refundable, non-transferable tuition deposit

(check or money order made payable to the Middle School of the Arts Foundation).

Tuition and Fees• Total Tuition $350

• Tuition Deposit $150 (non-refundable) due byMay 2, 2012

• Remainder of Tuition ($200) is due by May 23, 2012

Application TimelineA complete application packet MUST include ALL of the following:

• Application – ALL LINES COMPLETED by May 2, 2012

• Tuition Deposit of $150 by May 2, 2012(non-refundable, non-transferable) (check or money ordermade payable to Middle School of the Arts Foundation)

• Emergency Contact and Consent forms by May 15, 2012

Sample DaysDay 1:9:00am – 12:00pm Placement ExamsDuring the placement exams,Juilliard students will superviseactivities for the campers.

12:00pm Lunch1:00pm Small Ensembles/Combo2:00pm Listening Sessions3:00pm Large Ensembles4:15pm Jam Session5:00pm Dismissal

Juilliard JAZZSummer 2012 Camps and Workshops West Palm Beach, FL •June 11-15 •June 18-22

Program ScheduleThe day begins with MusicianshipClass followed by Individual Practiceand Small Ensembles/Combo work.After lunch, students have additionalensemble rehearsals, listeningsessions, Big Band rehearsal, and adaily Jam Session. In addition to thedaily classes and rehearsals, therepertoire studies during the weekwill be performed on the final day ofthe residency. Program structure maybe adjusted according to enrollment.

Students will be in session from9:00 am to 5:00 pm with dailyrequired practice sessions.

Day 2-4:9:00am Musicianship

10:00am Individual Practice11:00am Small Ensembles/Combo12:00pm Lunch1:00pm Small Ensembles/Combo2:00pm Listening Sessions3:00pm Large Ensembles4:15pm Jam Session5:00pm Dismissal

Day 5:9:00am – 11:00am Ensemble Rehearsal

11:00am – 1:00pm Dress Rehearsal1:00pm – 2:30pm Lunch/Break2:30pm Concert Run-Through4:00pm Dinner6:00pm ConcertDaily schedule is subject to change.

Section 1: Applicant InformationPlease fill out the application completely. Should you have any questions during the application process, please do not hesitate to contact the Office of Jazz Studies at (212) 799-5000, ext. 7380.

Name: __________________________________________________________________________________________________________________________First Middle Last

Primary Address: ________________________________________________________________________________________________________________Street Address Apt Number

_______________________________________________________________________________________________________________________________City State Zip Code

_______________________________________________________________________________________________________________________________Home Phone Number Cell Phone Number E-mail Address

� Male � Female Date of Birth: _______________ Age as of September 1, 2011: _______ T-Shirt Size: � XS � S � M � L � XLMM/DD/YY

How did you receive the brochure and application form? (Please be specific) ______________________________________________________________

INSTRUMENT (circle one):

trumpet tenor saxophone alto saxophone baritone saxophone trombone drums double bass electric bass guitar piano

Section 2: School InformationName of School attended September 2011: _______________________________________________________________________________________________

School Address: ________________________________________________________________________ School Phone: ____________________________

Music Teacher at School: __________________________________________________________________________________________________________

Name of School attending September 2012: _____________________________________________________ Grade Level in September 2012: ________

Musical Background

Primary Music Teacher: ___________________________________________________________________________________________________________

Years of Study: ________________ Have you taken private lessons? � Yes � No If yes, how long? ______________________________________

Other Instruments played: _______________________________________ Other Music Program(s) attended: ____________________________________

Background Information

Ethnic Background (optional): � African, African-American � Hispanic American, Latino � Multi-racial (specify): ____________________________

� Asian American � Native American, American Indian � Caucasian American � Other (specify): _______________________________________

Section 3: Parent/Guardian InformationChild Lives with: (Circle One) Mother Father Both Other: __________________________________________________________

Mother/Guardian Name: ___________________________________________________________________________________________________________First Middle Last

Primary Address: _________________________________________________________________________________________________________________Street Address Apt Number

_______________________________________________________________________________________________________________________________City State Zip Code

_______________________________________________________________________________________________________________________________Home Phone Number Work Phone Number Cell Phone Number

_______________________________________________________________________________________________________________________________E-mail Address (1) E-mail Address (2)

Father/Guardian Name: ____________________________________________________________________________________________________________First Middle Last

Primary Address: ________________________________________________________________________________________________________________Street Address Apt Number

_______________________________________________________________________________________________________________________________City State Zip Code

_______________________________________________________________________________________________________________________________Home Phone Number Work Phone Number Cell Phone Number

_______________________________________________________________________________________________________________________________E-mail Address (1) E-mail Address (2)

I certify that the information offered in this application is true and complete.

Parent/Guardian Signature: __________________________________________________________________________ Date:___________________________

Mail application and $150 non-refundable/non-transferable tuition deposit (check or money order made payable to Middle School of theArts Foundation) to: Mr. Cleve Maloon, Bak Middle School of the Arts, 1725 Echo Lake Drive, West Palm Beach, FL 33407 • (561) 882-3892

Juilliard JAZZSummer 2012 Camps and Workshops • West Palm Beach, FL

Application (Application Deadline: May 2, 2012)

Residency (check one) � June 11-15 � June 18-22

Residency Participant Name: ______________________________________________________________________________ Gender: � Male � FemaleFirst Middle Last

Address: _______________________________________________________________________________________________________________________Street Address Apt Number

_______________________________________________________________________________________________________________________________City State Zip Code

_______________________________________________________________________________________________________________________________Home Phone Number Cell Phone Number

Date of Birth: ______________MM/DD/YY

Parent/guardian

Name: ___________________________________________________________________________________________________________________________First Middle Last

Home Address: ___________________________________________________________________________________________________________________(if different from above): Street Address Apt Number

_______________________________________________________________________________________________________________________________City State Zip Code

Business name and address: ________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________Home Phone Number Business Phone Number

Second parent/guardian

Name: ___________________________________________________________________________________________________________________________First Middle Last

Home Address: ___________________________________________________________________________________________________________________(if different from above): Street Address Apt Number

_______________________________________________________________________________________________________________________________City State Zip Code

Business name and address: ________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________Home Phone Number Business Phone Number

Emergency Contact Information:Please list an emergency contact, other than parent or guardian, who will be available to pick up child if needed during residency

Name: ___________________________________________________________________________________________________________________________

Relationship to residency participant: _________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________Home Phone Number Cell Phone Number Work Phone

In the event a child needs to see a physician, the School District of Palm Beach County cannot be responsible for transportation to and from the doctor. The custodial parent orguardian will be notified to come and transport the child, or in the case of an emergency, the child will be transported by EMT services. In this document, “School District of PalmBeach County” means the sponsor of the activities in which the registrant engages in the school known as Bak Middle School of the Arts. Also in this document, school propertyrefers to instruments and equipment owned by School District of Palm Beach County or The Juilliard School.

Permission to Provide Necessary Treatment or Emergency Care: I hereby give permission to the medical personnel to order X-rays, routine tests, and treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation, for me or my child. In the event my child experiences a medical emergency, and residency personnel try but fail to reach me or under the circumstances are without sufficient time to try to reach me, I hereby give permission to the physician or other medicalpersonnel to secure and administer treatment, including hospitalization, anesthesia, surgery, and injections of medication for my child. As long as the medical treatment considerednecessary in the situation is in accordance with generally accepted standards of medical practice for the particular type of injury or illness involved, I impose no specific limitations orprohibitions regarding treatment other than the following: ________________________________________________________________________________________________

Signature of parent or guardian ________________________________________________________________ Date: ______________________________

Relationship to residency participant: _______________________________________________________________________________________________

NAME OF PARENT OR GUARDIAN (PLEASE PRINT): ______________________________________________________________________________________

Juilliard JAZZSummer 2012 Camps and Workshops • West Palm Beach, FL

Emergency Contact FormResidency (check one) � June 11-15 � June 18-22

Insurance Information

Is the participant covered by family medical/hospital insurance? _________________________________________________________________________

Indicate carrier or plan name _____________________________________________________ Group # _________________________________________

Name of insured _____________________________________________________ Relationship to residency participant ____________________________

Social security number of policy holder or insurance ID number _________________________________________________________________________

Please submit a copy – front and back of your health insurance card.

Does your child have a Behavior Intervention Plan (BIP) at his/her school? � Yes � No

Does your child take medication for behavior issues during the school year? � Yes � No

If yes, will he/she be taking this medication at the residency? If yes, please explain below. � Yes � No

Does your child have health problems? � Yes � No

If yes, please explain: ___________________________________________________________________________________________________________

Please list special diet/food allergies: ____________________________________________________________________________________________

Allergies:

� Hay Fever � Penicillin � Drugs � Insect Bites

� Nuts: what kind ________________________ � Asthma � Food � Other

Please provide additional specific details ________________________________________________________________________________

PLEASE NOTE: Any accidents and illnesses must be reported to School District of Palm Beach County/Juilliard staff before the participant leaves the

school each day. The residency participant is not allowed to possess any type of medicine on school grounds unless he or she has a letter of

explanation.

Please note the medication must be in the original prescription container/bottle with the name and an explanation note from the prescribing physician.

Over the counter medication should be brought in the original container with a parent note of explanation. All explanation notes and medicines should

remain with the residency participant at all times. The School District of Palm Beach County and Juilliard are not responsible for monitoring and

dispensing medication.

PARENT/GUARDIAN AUTHORIZATION: The residency participant described has permission to engage in all residency activities except as noted by

me in a separate letter (to be submitted with application). The residency participant and his/her parent/guardian agree to abide by the rules and

regulations set up by the School District of Palm Beach County for health, safety and welfare of the residency. The following violations of residency

rules will result in immediate dismissal without refund of fees:

1) Leaving Bak Middle School of the Arts without permission.

2) Willful destruction of school property.

3) Use of drugs and/or alcoholic beverages.

4) Fighting and/or continued insubordinate behavior resulting in disrupting of the residency program.

Parent/Guardian Signature __________________________________________________________________________ Date _________________________

Residency Participant Signature ______________________________________________________________________ Date _________________________

Juilliard JAZZSummer 2012 Camps and Workshops • West Palm Beach, FL

CONSENT FORM

All scheduled activities (both on & off campus) are closely supervised. Please check yes or no for each statement, and sign at bottom of page.

• I give permission for my child’s name, picture, or video clips taken of my son/daughter to be used in School District of Palm BeachCounty/Juilliard publicity or publications.

� Yes � No

• I understand that I am responsible and financially liable for the medical care of my child. In case of an emergency and I cannot benotified, the school has permission to seek medical attention for my child.

� Yes � No

• I agree that I will not hold the School District of Palm Beach County and The Juilliard School responsible for any accidents, injuries orother harm occurring to my child during the residency.

� Yes � No

Parent Printed Name _____________________________________________________________________________________________________________

Signature Parent/Guardian __________________________________________________________________________ Date _________________________

Completed emergency contact and consent forms must be received no later than May 15, 2012.

Mail to:

Mr. Cleve MaloonBak Middle School of the Arts1725 Echo Lake DriveWest Palm Beach, FL 33407

Questions? Please call Ms. Rebekah Gilbert (212) 799-5000 ext. 7380 or Mr. Cleve Maloon (561) 882-3892.

Parent/Guardian (Printed) _________________________________________________________________________________________________________

Parent/Guardian (Signature) __________________________________________________________________________ Date ________________________

Notary Legal Name (Printed) ________________________________________________________________________________________________________________________________

Notary (Signature) __________________________________________________________________________________ Date ________________________

Commission Expiration Date: _______________________________________________ State: ________________________________________________

Notary Seal

Juilliard JAZZSummer 2012 Camps and Workshops • West Palm Beach, FL

Consent FormResidency (check one) � June 11-15 � June 18-22

60 Lincoln Center Plaza, New York, NY 10023

www. juilliard.edu

Joseph W. Polisi, PresidentPh

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