1. Healthcare

 GR!DSM 2015 CAMPER REGISTRATION FORM
Camp Dates: Monday – Friday, June 15 – June 26, 2015
9:00am – 4:30pm
Location: Hubbell Elementary School, 800 42nd St. Des Moines, IA, 2nd Floor
I. Camper Contact Information
Name of Camper ____________________________________________________________
Age at the time of camp ____ What should we call you at camp? ______________
Home Address _______________________________________________________________
City ___________________________________ State ________ Zip __________
Mailing Address (if different from above)_______________________________________
City __________________________________ State ________ Zip __________
Camper’s Email Address ____________________________________________________
Parent/Guardian Name ______________________________________________________
Home Phone (____) _____ - ________ Cell (____) _____-______
Work (_____) ____-______
Parent/Guardian Email Address_________________________________________________
Emergency Contacts
Contact Name 1 _____________________________________________________________
Relationship to Camper_______________________________________________________
Home Phone (____) _____ - ________ Cell (____) _____-______
Work (_____) ____-______
Contact Name 2 _____________________________________________________________
Relationship to Camper_______________________________________________________
Home Phone (____) _____ - ________ Cell (____) _____-______
Work (_____) ____-______
Camper Name_______________________________
Medical Information
Does the camper have any medical conditions or allergies?
Yes__ No__ If yes, please explain:
______________________________________________________________________________
Does the camper have any diagnosed behavioral or emotional issues?
Yes__ No__ If yes, please explain:
_____________________________________________________________________________
Is she on any medications to treat any of the aforementioned conditions?
Yes__ No__ If yes, please list medication and specify condition:
_____________________________________________________________________________
Other
Camper T-shirt size preference:
Youth ! M ! L
Unisex
Adult
! Medium
S ! M ! L ! XL ! XXL
GR!DSM encourages campers who can to bring sack lunches for each day of camp. However, we
can provide lunch every day of camp for our campers. Please sign up only if you intend to have lunch
provided every day. Please note, signing up to have lunch provided is an additional $50 in tuition.
Would you like GR!DSM to provide a lunch for you? No,
! Yes
No
my!
camper
will bring lunch from home every day.
None
If yes, please indicate if you are !
Vegan ! Vegetarian ! Gluten Free or !
Other______________________
Do you have any food allergies or medical information you would like us to know about?
Camper Name_______________________________
______________________________________________________________________________
II. Camper Music Information - NO EXPERIENCE NECESSARY!!!
GR!DSM offers dj, bass, guitar, keyboards, voice, and drum instruction. Put a check by your first instrument
choice in the first choice column, a check by your second choice, etc. We will do our best to give you your
first choice, but we also want to make sure are a variety of instruments to help you form a band, so you
may get your 2nd or 3rd choice. No matter the choice, we know you’ll have a great time! **Please note the
availability of DJ instruction is solely dependent on the availability of instructors.**
DJ - subject to instructor availability
1st Choice_______________________
DJ - subject to instructor availability
2nd Choice______________________
DJ - subject to instructor availability
3rd Choice______________________
1st Choice
I have never played this instrument
before.
I have been playing this instrument
casually (on and off).
I have played this instrument
seriously for 3+ months.
I have played this instrument a lot/
had previous lessons (1+ years).
2nd Choice
I have never played this
instrument before.
I have been playing this
instrument casually (on and off).
I have played this instrument
seriously for 3+ months.
I have played this instrument
a lot/ had previous lessons (1+
3rd Choice
I have never played this instrument
before.
I have been playing this instrument
casually (on and off).
I have played this instrument
seriously for 3+ months.
I have played this instrument a lot/
had previous lessons (1+ years).
years).
While at camp, you’ll receive instrument lessons, have band practice and individual practice time, and take
classes from our core curriculum, which includes the following: I Rock! (Empowerment Class), Music Art,
and Technology and Recording.
Camper Name_______________________________
Elective Classes
In addition to our core curriculum (see previous section) you will also be able to take some elective classes
based on your interest. Below are descriptions of all the classes available at camp. Rank your top six
choices (From 1: This is the class I absolutely HAVE to take! to 6: I could be interested in this.) for classes
you’d like to take. We will do our best to give you your top choices. Please select the classes you’d be
interested in taking at camp:
____How
to Rock
No Thank
You!on Stage! - This course will teach you how to release your inner rock star and take
ownership of the stage. When you are up there, command the audience and have them captivated by your
awesomeness.
____How
to Rock
No Thank
You!an Interview! - Interested in being the front person in your band or nervous about what to
say during interviews? You'll learn how to prepare for and practice interviews with each other and get
interviewed by local media!
No Thank
You!of Sound - You will learn how the journey of sound waves affects the brain, the music we
____The
Physics
hear, and how we interpret it. You will get to participate in exciting “sound” labs as you recreate sound
waves and patterns based on musical tones.
No Thank You!– You will learn about how to write strong lyrics using research-based methods used by
____Songwriting
the pros and will complete the course by writing and recording your own original song you created!
____Intro
to Rocking
No Thank
You! Music Theory! - This course explains the theory behind music and will teach the
campers how to read basic music and how to construct rhythms.
No
Thank
____How
to You!
Rock at Jamming! – (This course is recommended for campers with previous experience with
their instrument) You will have the opportunity to exercise your improv skills as you collaborate with fellow
musicians from the camp and rock out to songs that you may have never heard before!
No Thank
You!at Getting a Gig! - You can do a lot to promote your band’s image and build publicity to
____How
to Rock
get a crowd.
___How
to Rock
No
Thank
You!at Playing your Favorite Song Now! - Bring in your favorite songs that you’ve always
wanted to play and we’ll show you how to do it by learning how to read instrument TABS.
No Thank You!
____Herstory
of Women in Music - There are so many amazing women (like yourself) that have influenced
rock and roll history. Learn about how women have rocked the charts with their stories and experiences
throughout the 20th Century.
No
ThankInYou!
____Music
the Media! - How does media impact our view of music, performers and ourselves? Media
analysis class. Bring your music magazines!
Camper Name_______________________________
What is your overall experience, if any, with musical instruments and/or singing?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Who are your favorite bands/artists? Pick 3-5 only please…We know it’s hard! ☺
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
We know it's tough to pick/label the kind of music you like to listen to or create, but this will help us help you
match up with great bandmates. Select only 3 – 5.
____IndieSongwriter
Rock
Singer
____Singer/Songwriter
Classic
Rock
____Classic
Rock
Punk
____Punk
R&B
____R&B
Metal
____MetalHop
Rap/Hip
____Rap/Hip-Hop
Pop
Music (top 40)
____Pop Music (Top 40)
Jazz
____Jazz
Reggae
____Reggae
Country
____Country
Latin
____Latin Rock
Modern
____Modern Rock
Oldies
____Oldies
Other
____Other
Please list anything else you would like for us to know about you:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Camper Name_______________________________
______________________________________________________________________________
III. Payment Information
Day Camp: Monday – Friday, June 15 – June 26, 2015, 900am – 430pm
_____2-week program fee: $425 for each session
_____Early Bird Registration fee available to first 20 non-scholarship campers for each session: $400 (To
receive the early bird rate, payment is due before March 1, 2015)
_____Optional Green Room Time (Early Drop Off/Late Pick Up) fee: $50
Early Drop off (no earlier than 7:45am) and Late Pick up (no later than 5:30pm)
_____GR!DSM will provide lunch for me: $50
TOTAL TUITION $____________
If you are applying for a scholarship, GR!DSM will contact you to let you know your scholarship award.
Once you are notified, tuition is due on or before the first day of camp.
Please make your check payable to Girls Rock!Des Moines, and mail to:
GR!DSM
206 6th Avenue
3rd Floor
Des Moines, IA 50309
You can also pay online at
the GR!DSM Square Market.
Just click this link.
If you would like to apply for a need-based scholarship, click here to download the form.