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*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 Email* Director's/School's Phone* All-State FeesThe All-State fee of $60.00 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: $60.00 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 Parents/Guardians:Rules/Policies*By checking this, my child and I indicate we have read and understand the All-State Rules, Regulations, and Policies.Emergency Medical Treatment*By 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.Phone (Emergency Contact)*Parent/Guardian's Email*Parent/Guardian's Name* First Name Last Name Parent/Guardian's Electronic SignatureThe parent/guardian's signature is required to provide medical treatment in an emergency.Confirmation of Electronic Signature*I 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: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, 2017.Academic All-State 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. This form must be postmarked by October 22.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 email@example.com.