SASA Teacher Trainee 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.

CONTACT INFORMATION
* Last Name* First Name
* 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)    
 
* Date of Birth:     
 
  
* Gender* Instrument
 
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 CompanyPolicy/Group #
Family Doctor NameFamily 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?    
 
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?    
 
T-SHIRT PRE-ORDERS
Child Sizes - $16.00 each
S (6-8)  M (10-12)  L (14-16)  
 
Adult Sizes - $18.00 each
S (34-36)  M (38-40)  L (42-44)  XL (46-48)  
 
VOLUNTEER OPPORTUNITIES
Selecting at least one Volunteer Opportunity will qualify you for a $25.00 discount on your total registration fees.

Volunteer Name
EmailPhone
 
DONATIONS
Please consider making a tax deductible donation to SASA  $ 
 
ELECTIVES
These optional classes are in addition to the the daily core curriculum; additional fees apply as shown.
Selection 1:
Selection 2:
Alternate: