SASA Enrollment Application

Fields marked with * are required for submission. Leave field blank if it does not apply to you. If a field is required but does not apply to you, enter N/A.

PARENT / GUARDIAN INFORMATION - Registration info will be sent to this individual. NOTE: All children under age 12 must be accompanied by a responsible adult between classes and during free periods.

* Last Name	* First Name

Student Last Names (if different)


* Street

* City	* State	* Zip


* Email	* Preferred Phone (best to reach you at)

* Do you wish to be included in the directory? (lists of names, addresses and emails) Yes No

EMERGENCY CONTACT - Must be other than adult above. Person in local area to contact if above adult is not available in case of illness or emergency situation.

* Last Name	* First Name

* Street

* City	* State	* Zip


* Phone

MEDICAL INSURANCE

Insurance Company	Policy/Group #

Family Doctor Name	Family Doctor Phone
Special Needs/Allergies?

MEDICAL RELEASE
In order to attend the Institute, each family must have a signed Medical Release Form on file. This form will enable necessary medical treatment to be given to each child in the event of an emergency. I give my permission for a nurse, doctor, health center, or hospital staff to administer any necessary aid immediately to applicants should he/she/they become sick or injured while attending the SASA Institute, and to do so without having to wait until I am contacted. I also agree to hold harmless SASA and anyone affiliated with it for any injury incurred to any family member as a result of their participation. * Do you consent to the above medical release? Yes No

PHOTO/VIDEO RELEASE
I understand that SASA may take photographs and/or videos of institute participants and activities. I agree that the Suzuki Association of Southcentral Alaska may use such photographs and/or videos relating to the promotion of future activities. I relinquish all rights that I may claim in relation to the use of said photographs and/or videos. * Do you consent to the above photo/video release? Yes No

PROGRAM T-SHIRTS
Please only put a size in this field if you wish to order an EXTRA adult t-shirt. Current cost is $18 if pre-ordered, $20 if bought at the institute.


Volunteer Name

Email	Phone


DONATIONS
Please consider making a tax deductible donation to SASA $ We are a 501(c)3 organization. EIN 94-3235035.

VOLUNTEER OPPORTUNITIES
We need help to keep our costs down. Please consider volunteering for as many of these as you can. Meals can be shared between volunteers to make it easier.
Final Picnic	Front Desk Helper	Help Clean Up (Fri PM)
Help Set Up (Mon AM)	Ice Cream Social	Registration Packets
Silent Auction	Teacher's Meals	Teen Activities
Other As Needed