All-State Jazz Ensemble – Student Registration Form Student Information:Student's Name*Please list your child's name as you want it to appear in All-State concert program. First Name Last Name School*Grade*Student's EmailIf provided, this email will be used for updates related to the All-State Jazz Ensemble music. By providing this email, parents/guardians are giving permission for the LMEA Jazz Chair to contact their child with updated information.Instrument*Part your child is playing in the All-State Jazz EnsembleNumber of years in LMEA All-StateInclude this year in the numberT-Shirt Size (free to All-State members)*Select the correct size as it cannot be changed later.SmallMediumLargeX-LargeXX-LargeXXX-LargeMailing AddressBy providing your address, you are giving permission for the colleges and universities attending the All-State event to mail information about scholarships and university music programs to your child. Street Address or P.O. Box City Zip Additional Student Information*The above named student has no physical or medical condition that could cause a problem during All-State activities.The above named student has the following physical or medical condition that could cause a problem during All-State activities.List all physical or medical concerns or conditions that LMEA should be aware of. Director InformationDirector's Name* First Name Last Name School*Director's/School's Phone*Director's Email* Enter Email Confirm Email All-State FeesThe All-State fee of $65.00 must be received before a student's registration is complete.There are NO REFUNDS if the student does not participate.Meals and housing are not included.The All-State ensembles are partially funded by the Louisiana Music Educators Association Foundation.Select Method of Payment*I prefer to pay with Credit/Debit Card through this secure site.I prefer to pay with School Check. (observe school deadlines) NOTE: Your child’s registration IS NOT complete until payment has been received by LMEA.All-State Fee (Jazz Ensemble) Price: $65.00 Processing Fee $3.00 Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Name as it appear on card Billing Name First Last Billing Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code If paying by school check, directors should send the check to Lee Hicks, LMEA Jazz Division Chair, Fontainebleau High School, 100 Bulldog Dr., Mandeville, LA 70471. Directors must also send the names of any All-State Jazz Ensemble students whose registration fees are included in the check. Parents/Guardians:Parent/Guardian's Name* First Name Last Name Phone (Emergency Contact)*Parent/Guardian's Email* Enter Email Confirm Email Parent/Guardian's EmailEmergency Medical TreatmentBy electronically signing and submitting this form, I give my permission for my child to be given emergency treatment by qualified members of the medical profession, if such treatment should be necessary.Parent/Guardian's Electronic SignatureThe parent/guardian's signature is required to provide medical treatment in an emergency.Confirmation of Electronic SignatureI understand that by checking this box, I agree that my electronic signature constitutes a legal signature of this student's parent or legal guardian.Reminders:Rules/Policies*By checking this, my child and I indicate we have read and understand the All-State Rules, Regulations, and Policies.All-State Permission Form*There is a separate All-State Permission Form that must be completed, signed, and submitted as part of the registration process. This form includes a medical release and permission for emergency treatment. The postmark deadline is October 22, 2018.First ChoiceAll-State Academic Award*All-State Academic Award: If your child qualifies for this award, there is a separate form that must be printed, signed by the parent/guardian, director, and school official. The postmark deadline is October 22, 2018.Your All-State registration is not complete until payment has been received and your director has registered for the conference. All registration must be completed by October 22, 2018. Important: Click "Submit" once only.A copy of this registration form will be sent to the Parent/Guardian's email address provided above. If you do not receive it within a few minutes, check your junk folder. For additional problems, contact us at firstname.lastname@example.org.