Registration Form for Summer Jazz Camp

July 9th - July 13th 2018

First Name:

Last Name:

Address #1:

Address #2:


State: Zip:


Grade, Fall '18

Yrs Experience:

Improv. Experience:

Private Instructor:

School Name:

Adult T-Shirt Size (Check one):

Adult Small Adult Medium Adult Large Adult X-Large
Adult XX-Large

If interested in being a Counselor: (please check this box) Counselor

Prerequisites: Individual should be a college level student displaying a high level of accomplishment on his/her instrument (s) and the ability to assist others with their music and/or technical aspects of that instrument, in a professional manner.)


Parents name:

Home Phone:

Work Phone:

Email Address:

Fill out online and print out this form to register.
Please sign the form, include your check payable to "Tony Pietricola ", and mail to:

Tony Pietricola
Summer Jazz Camp
6 Old Town Lane
Grand Isle, VT 05458

Don't forget the T-Shirt Size. The shirt comes with the fee and we use it as part of the uniform for the concert.
Morning Session, $175.00
(Min. $50.00 Deposit, anytime before July 1.)

Full Day Session
(High School only),$275.00
(Min. $50.00 Deposit, anytime before July 1.)



Afternoon Session only
(High School only),$100.00
(Due anytime before July 1.)



I understand my $50.00 deposit is non-refundable in the event this student cannot attend.

Please sign in box
at right after printing:

Special Needs?
Any medication?